brimonidine + timolol


Indoco Remedies


Ophthamed Pharma


Full Prescribing Info
Brimonidine tartrate, timolol maleate.
Each mL contains: Brimonidine tartrate Ph. Eur. 2 mg, Timolol maleate Ph. Eur. equivalent to 5 mg of Timolol.
Preservative: Benzalkonium chloride 0.005%.
Excipients/Inactive Ingredients: Sodium phosphate monobasic monohydrate, Sodium phosphate dibasic heptahydrate, Hydrochloric acid or Sodium hydroxide (to adjust pH), Water for injection.
Pharmacology: Pharmacodynamics: Mechanism of action: Brimochek-T consists of two active substances: Brimonidine tartrate and Timolol maleate. These two components decrease elevated intraocular pressure (IOP) by complementary mechanisms of action and the combined effect results in additional IOP reduction compared to either compound administered alone. Brimochek-T has a rapid onset of action.
Brimonidine tartrate is an alpha2 adrenergic receptor agonist that is 1000 fold more selective for the alpha2 adrenoceptor than the alpha1 adrenoreceptor. This selectivity results in no mydriasis and the absence of vasoconstriction in microvessels associated with human retinal xenografts.
It is thought that Brimonidine tartrate lowers IOP by enhancing uveoscleral outflow and reducing aqueous humour formation.
Timolol is a beta1 and beta2 nonselective adrenergic receptor blocking agent that does not have significant intrinsic sympathomimetic, direct myocardial depressant, or local anaesthetic (membrane stabilising) activity. Timolol lowers IOP by reducing aqueous humour formation. The precise mechanism of action is not clearly established, but inhibition of the increased cyclic AMP synthesis caused by endogenous beta-adrenergic stimulation is probable.
Pharmacokinetics: Brimonidine: After ocular administration of 0.2% eye drops solution in humans, plasma brimonidine concentrations are low. Brimonidine is not extensively metabolised in the human eye and human plasma protein binding is approximately 29%. The mean apparent half-life in the systemic circulation was approximately 3 hours after topical dosing in man.
Following oral administration to man, brimonidine is well absorbed and rapidly eliminated. The major part of the dose (around 74% of the dose) was excreted as metabolites in urine within five days; no unchanged drug was detected in urine. In vitro studies, using animal and human liver, indicate that the metabolism is mediated largely by aldehyde oxidase and cytochrome P450. Hence, the systemic elimination seems to be primarily hepatic metabolism.
Brimonidine binds extensively and reversibly to melanin in ocular tissues without any untoward effects. Accumulation does not occur in the absence of melanin.
Brimonidine is not metabolised to a great extent in human eyes.
Timolol: After ocular administration of a 0.5% eye drops solution in humans undergoing cataract surgery, peak timolol concentration was 898 ng/ml in the aqueous humour at one hour postdose. Part of the dose is absorbed systemically where it is extensively metabolised in the liver. The half-life of timolol in plasma is about 7 hours. Timolol is partially metabolised by the liver with timolol and its metabolites excreted by the kidney. Timolol is not extensively bound to plasma protein.
For reduction of intraocular pressure (IOP) in patients with chronic open-angle glaucoma or ocular hypertension who are insufficiently responsive to topical beta-blockers.
Dosage/Direction for Use
Posology: Paediatric population: Brimochek-T is contraindicated in neonates and infants (less than 2 years of age).
The safety and effectiveness of Brimochek-T in children and adolescents (2 to 17 years of age) have not been established and therefore, its use is not recommended in children or adolescents.
Recommended dosage in adults (including the elderly): The recommended dose is one drop of Brimochek-T in the affected eye(s) twice daily, approximately 12 hours apart. If more than one topical ophthalmic product is to be used, the different products should be instilled at least 5 minutes apart.
Or as prescribed by the physician.
Method of administration: As with any eye drops, to reduce possible systemic absorption, it is recommended that the lachrymal sac be compressed at the medial canthus (punctual occlusion) or eyelids are closed for two minutes. This should be performed immediately following the instillation of each drop. This may result in a decrease of systemic side effects and an increase in local activity.
To avoid contamination of the eye or eye drops do not allow the dropper tip to come into contact with any surface.
Use in renal and hepatic impairment: Brimochek-T has not been studied in patients with hepatic or renal impairment. Therefore, caution should be used in treating such patients.
Rare reports of overdosage with Brimochek-T in humans resulted in no adverse outcome. Treatment of an overdose includes supportive and symptomatic therapy a patient's airway should be maintained.
Brimonidine: Ophthalmic overdose (Adults): In those cases received, the events reported have generally been those already listed as adverse reactions.
Systemic overdose resulting from accidental ingestion (Adults): There is very limited information regarding accidental ingestion of brimonidine in adults. The only adverse event reported to date was hypotension. It was reported that the hypotensive episode was followed by rebound hypertension. Oral overdoses of other alpha 2 agonists have been reported to cause symptoms such as hypotension, asthenia, vomiting, lethargy, sedation, bradycardia, arrhythmias, miosis, apnoea, hypotonia, hypothermia, respiratory depression and seizure.
Paediatric population: Reports of serious adverse effects following inadvertent ingestion of Alphagan by paediatric subjects have been published or reported to Allergan. The subjects experienced symptoms of CNS depression, typically temporary coma or low level of consciousness, lethargy, somnolence, hypotonia, bradycardia, hypothermia, pallor, respiratory depression and apnoea, and required admission to intensive care with intubation if indicated. All subjects were reported to have made a full recovery, usually within 6-24 hours.
Timolol: Symptoms of systemic timolol overdose include: bradycardia, hypotension, bronchospasm, headache, dizziness and cardiac arrest. A study of patients showed that timolol did not dialyse readily.
Hypersensitivity to the active substances or to any of the excipients.
Reactive airway disease including bronchial asthma or a history of bronchial asthma, severe chronic obstructive pulmonary disease.
Sinus bradycardia, sick sinus syndrome sinoatrial block, second or third degree atrioventricular block not controlled with a pacemaker, overt cardiac failure, cardiogenic shock.
Use in neonates and infants (less than 2 years of age).
Patients receiving monoamine oxidase (MAO) inhibitor therapy.
Patients on antidepressants which affect noradrenergic transmission (e.g. tricyclic antidepressants and mianserin).
Special Precautions
Cardiac disorders: Cardiac reactions have been reported including, rarely, death associated with cardiac failure following administration of timolol. In patients with cardiovascular diseases (e.g. coronary heart disease, Prinzmetal's angina and cardiac failure) and hypotension therapy with beta-blockers should be critically assessed and the therapy with other active substances should be considered. Patients with cardiovascular diseases should be watched for signs of deterioration of these diseases and of adverse reactions.
Due to its negative effect on conduction time, beta-blockers should only be given with caution to patients with first degree heart block.
As with systemic beta-blockers, if discontinuation of treatment is needed in patients with coronary heart disease, therapy should be withdrawn gradually to avoid rhythm disorders, myocardial infarct or sudden death.
Vascular disorders: Patients with severe peripheral circulatory disturbance/disorders (i.e. severe forms of Raynaud's disease or Raynaud's syndrome) should be treated with caution.
Respiratory disorders: Respiratory reactions, including death due to bronchospasm in patients with asthma have been reported following administration of some ophthalmic beta-blockers.
Brimochek-T should be used with caution, in patients with mild/moderate chronic obstructive pulmonary disease (COPD) and only if the potential benefit outweighs the potential risk.
Hypoglycaemia/diabetes: Beta-blockers should be administered with caution in patients subject to spontaneous hypoglycaemia or to patients with labile diabetes, as beta-blockers may mask the signs and symptoms of acute hypoglycaemia.
Hyperthyroidism: Beta-blockers may also mask the signs of hyperthyroidism. Brimochek-T must be used with caution in patients with metabolic acidosis and untreated pheochromocytoma.
Corneal diseases: Ophthalmic beta-blockers may induce dryness of eyes. Patients with corneal diseases should be treated with caution.
Other beta-blocking agents: The effect on intraocular pressure or the known effects of systemic beta blockade may be potentiated when timolol is given to the patients already receiving a systemic beta-blocking agent. The response of these patients should be closely observed. The use of two topical beta adrenergic blocking agents is not recommended.
Anaphylactic reactions: While taking beta-blockers, patients with a history of atopy or a history of severe anaphylactic reaction to a variety of allergens may be more reactive to repeated challenge with such allergans and unresponsive to the usual dose of adrenaline used to treat anaphylactic reactions.
Choroidal detachment: Choroidal detachment has been reported with administration of aqueous suppressant therapy (e.g. timolol, acetazolamide) after filtration procedures.
Surgical anaesthesia: Beta-blocking ophthalmological preparations may block systemic beta-agonist effects e.g. of adrenaline. The anaesthetist must be informed if the patient is receiving timolol.
The preservative in Brimochek-T, benzalkonium chloride, may cause eye irritation. Remove contact lenses prior to application and wait at least 15 minutes before reinsertion. Benzalkonium chloride is known to discolour soft contact lenses. Avoid contact with soft contact lenses. Brimochek-T has not been studied in patients with closed-angle glaucoma.
Effects on Ability to Drive and Use Machines: Brimochek-T has minor influence on the ability to drive and use machines. Brimochek-T may cause transient blurring of vision, visual disturbance, fatigue and/or drowsiness which may impair the ability to drive or operate machines. The patient should wait until these symptoms have cleared before driving or using machinery.
Use in Children: Children of 2 years of age and above, especially those in the 27 age range and/or weighing ≤20 Kg, should be treated with caution and closely monitored due to the high incidence and severity of somnolence. The safety and effectiveness of Brimochek-T in children and adolescents (2 to 17 years of age) have not been established.
Allergic conjunctivitis was seen in 5.2% of patients. Onset was typically between 3 and 9 months resulting in an overall discontinuation rate of 3.1%.
Allergic blepharitis was uncommonly reported (<1%). If allergic reactions are observed, treatment with Brimochek-T should be discontinued.
Delayed ocular hypersensitivity reactions have been reported with Brimonidine tartrate ophthalmic solution 0.2%, with some reported to be associated with an increase in IOP.
Like other topically applied ophthalmic agents, Brimochek-T may be absorbed systemically. No enhancement of the systemic absorption of the individual active substances has been observed. Due to beta-adrenergic component, timolol, the same types of cardiovascular, pulmonary and other adverse reactions seen with systemic beta-adrenergic blocking agents may occur. Incidence of systemic ADRs after topical ophthalmic administration is lower than for systemic administration. To reduce the systemic absorption.
Use In Pregnancy & Lactation
Pregnancy: There are no adequate data for the use of the brimonidine timolol fixed combination in pregnant women. Brimochek-T should not be used during pregnancy unless clearly necessary.
Brimonidine tartrate: There are no adequate data from the use of Brimonidine tartrate in pregnant women. Studies in animals have shown reproductive toxicity at high maternotoxic doses. The potential risk for humans is unknown.
Timolol: Studies in animals have shown reproductive toxicity at doses significantly higher than would be used in clinical practice.
Epidemiological studies have not revealed malformative effects but have shown a risk for intra uterine growth retardation when beta-blockers are administered by the oral route. In addition, signs and symptoms of beta-blockade (e.g. bradycardia, hypotension, respiratory distress and hypoglycaemia) have been observed in the neonate when beta-blockers have been administered until delivery. If Brimochek-T is administered in pregnancy up to the time of delivery, the neonate should be carefully monitored during the first days of life.
Breast-feeding: Brimonidine tartrate: It is not known if brimonidine is excreted in human milk but it is excreted in the milk of the lactating rat.
Timolol: Beta-blockers are excreted in breast milk. However, at therapeutic doses of timolol in eye drops it is not likely that sufficient amounts would be present in breast milk to produce clinical symptoms of beta-blockade in the infant. To reduce the systemic absorption.
Brimochek-T should not be used by women breast-feeding infants.
Adverse Reactions
Based on 12 month clinical data, the most commonly reported ADRs were conjunctival hyperaemia (approximately 15% of patients) and burning sensation in the eye (approximately 11% of patients). The majority of these cases was mild and led to discontinuation rates of only 3.4% and 0.5% respectively.
The following adverse drug reactions were reported: Eye disorders: Very Common (>1/10): conjunctival hyperaemia, burning sensation. Common (>1/100, <1/10): stinging sensation in the eye, allergic conjunctivitis, corneal erosion, superficial punctuate keratitis, eye pruritus, conjunctival folliculosis, visual disturbance, blepharitis, epiphora, eye dryness, eye discharge, eye pain, eye irritation, foreign body sensation. Uncommon (>1/1000, <1/100): visual acuity worsened, conjunctival oedema, follicular conjunctivitis, allergic blepharitis, conjunctivitis, vitreous floater, asthenopia, photophobia, papillary hypertrophy, eyelid pain, conjunctival blanching, corneal oedema, corneal infiltrates, vitreous detachment.
Psychiatric disorders: Common (>1/100, <1/10): depression.
Nervous system disorders: Common (>1/100, <1/10): somnolence, headache. Uncommon (>1/1000, <1/100): dizziness, syncope.
Cardiac disorders: Uncommon (>1/1000, <1/100): congestive heart failure, palpitations.
Vascular disorders: Common (>1/100, <1/10): hypertension.
Respiratory, thoracic and mediastinal disorders: Uncommon (>1/1000, <1/100): rhinitis, nasal dryness.
Gastrointestinal disorders: Common (>1/100, <1/10): oral dryness. Uncommon (>1/1000, <1/100): taste perversion, nausea, diarrhoea.
Skin and subcutaneous tissue disorders: Common (>1/100, <1/10): eyelid oedema, eyelid pruritus, eyelid erythema. Uncommon (>1/1000, <1/100): allergic contact dermatitis.
General disorders and administration site conditions: Common (>1/100, <1/10): asthenic conditions.
The following adverse drug reactions have been reported since Brimochek-T has been marketed: Eye disorders: Not known: vision blurred.
Cardiac disorders: Not known: arrhythmia, bradycardia, tachycardia.
Vascular disorders: Not known: hypotension.
Skin disorders: Not known: erythema facial.
Additional adverse events that have been seen with one of the components and may potentially occur.
Brimonidine: Eye disorders: iritis, iridocyclitis (anterior uveitis), miosis.
Psychiatric disorders: insomnia.
Respiratory, thoracic and mediastinal disorders: upper respiratory symptoms, dyspnoea.
Gastrointestinal disorders: gastrointestinal symptoms.
General disorders and administration site conditions: systemic allergic reactions.
Skin and subcutaneous tissue disorders: skin reaction including erythema, face oedema, pruritus, rash and vasodilatation.
In cases where brimonidine has been used as part of the medical treatment of congenital glaucoma, symptoms of brimonidine overdose such as loss of consciousness, lethargy, somnolence, hypotension, hypotonia, bradycardia, hypothermia, cyanosis, pallor, respiratory depression and apnoea have been reported in neonates and infants (less than 2 years of age) receiving brimonidine.
A high incidence and severity of somnolence has been reported in children of 2 years of age and above, especially those in the 27 age range and/or weighing ≤20 Kg.
Timolol: Like other topically applied ophthalmic drugs, Brimochek-T (Brimonidine tartrate/ timolol) is absorbed into the systemic circulation. Absorption of timolol may cause similar undesirable effects as seen with systemic beta-blocking agents.
Incidence of systemic ADRs after topical ophthalmic administration is lower than for systemic administration. To reduce the systemic absorption.
Additional adverse reactions that have been seen with ophthalmic beta-blockers and may potentially occur also with Brimochek-T are listed as follows: Immune system disorders: systemic allergic reactions including angioedema, urticaria, localised and generalised rash, pruritis, anaphylactic reaction.
Metabolism: hypoglycaemia.
Psychiatric disorders: insomnia, nightmares, memory loss.
Nervous system disorders: cerebrovascular accident, cerebral ischemia, increases in signed and symptoms of myasthenia gravis, paraesthesia.
Eye disorders: keratitis, choroidal detachment following filtration surgery (see Precautions), decreased corneal sensitivity, corneal erosion, ptosis, diplopia.
Cardiac disorders: chest pain, oedema, atrioventricular block, cardiac arrest, cardiac failure.
Vascular disorders: Raynaud's phenomenon, cold hands and feet.
Respiratory, thoracic, and mediastinal disorders: bronchospasm (predominantly in patients with preexisting bronchospastic disease), dyspnoea, cough.
Gastrointestinal disorders: dyspepsia, abdominal pain, vomiting.
Skin and subcutaneous tissue disorders: alopecia, psoriasiform rash or exacerbation of psoriasis, skin rash.
Musculoskeletal and connective tissue disorders: myalgia.
Reproductive system and breast disorders: sexual dysfunction, decreased libido.
General disorders and administration site conditions: fatigue.
Adverse reactions reported in eye drops containing phosphates: Cases of corneal calcification have been reported very rarely in association with the use of phosphate containing eye drops in some patients with significantly damaged corneas.
Drug Interactions
No interaction studies have been performed with the brimonidine timolol fixed combination. Although specific drug interactions studies have not been conducted with Brimochek-T, the theoretical possibility of an additive or potentiating effect with CNS depressants (alcohol, barbiturates, opiates, sedatives, or anaesthetics) should be considered.
There is a potential for additive effects resulting in hypotension, and/or marked bradycardia when ophthalmic beta-blockers solution is administered concomitantly with oral calcium channel blockers, beta-adrenergic blocking agents, anti-arrhythmics (including amiodarone), digitalis glycosides, parasympathomimetics or guanethidine. Also, after the application of brimonidine, very rare (<1 in 10,000) cases of hypotension have been reported. Caution is therefore advised when using Brimochek-T with systemic antihypertensives.
Mydriasis resulting from concomitant use of ophthalmic beta-blockers and adrenaline (epinephrine) has been reported occasionally. Beta-blockers may increase the hypoglycaemic effect of antidiabetic agents. Beta-blockers can mask the signs and symptoms of hypoglycaemia.
The hypertensive reaction to sudden withdrawal of clonidine can be potentiated when taking beta-blockers.
Potentiated systemic beta-blockade (e.g., decreased heart rate, depression) has been reported during combined treatment with CYP2D6 inhibitors (e.g. quinidine, fluoxetine, paroxetine) and timolol.
Concomitant use of a beta-blocker with anaesthetic drugs may attenuate compensatory tachycardia and increase the risk of hypotension and therefore the anaesthetist must be informed if the patient is using Brimochek-T.
Caution must be exercised if Brimochek-T is used concomitantly with iodine contrast products or intravenously administered lidocaine.
Cimetidine, hydralazine and alcohol may increase the plasma concentrations of timolol.
No data on the level of circulating catecholamines after Brimochek-T administration are available. Caution, however, is advised in patients taking medication which can affect the metabolism and uptake of circulating amines e.g. chlorpromazine, methylphenidate, reserpine.
Caution is advised when initiating (or changing the dose of) a concomitant systemic agent (irrespective of pharmaceutical form) which may interact with adrenergic agonists or interfere with their activity i.e. agonists or antagonists of the adrenergic receptor e.g. (isoprenaline, prazosin).
Although specific drug interactions studies have not been conducted with Brimochek-T, the theoretical possibility of an additive IOP lowering effect with prostamides, prostaglandins, carbonic anhydrase inhibitors and pilocarpine should be considered.
Brimonidine is contraindicated in patients receiving monoamine oxidase (MAO) inhibitor therapy and patients on antidepressants which affect noradrenergic transmission (e.g. tricyclic antidepressants and miaserin). Patients who have been receiving MAOI therapy should wait 14 days after discontinuation before commencing treatment with Brimochek-T.
Store at temperatures not exceeding 30°C. Protect from light.
ATC Classification
S01ED51 - timolol, combinations ; Belongs to the class of beta blocking agents. Used in the treatment of glaucoma.
Ophth soln 5 mL x 1's.
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