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Cutivate

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Cutivate Cream

CLINICAL PHARMACOLOGY

Like other topical corticosteroids, fluticasone propionate has anti-inflammatory, antipruritic, and vasoconstrictive properties. The mechanism of the anti-inflammatory activity of the topical steroids, in general, is unclear. However, corticosteroids are thought to act by the induction of phospholipase A2 inhibitory proteins, collectively called lipocortins. It is postulated that these proteins control the biosynthesis of potent mediators of inflammation such as prostaglandins and leukotrienes by inhibiting the release of their common precursor, arachidonic acid. Arachidonic acid is released from membrane phospholipids by phospholipase A2.

Fluticasone propionate is lipophilic and has a strong affinity for the glucocorticoid receptor. It has weak affinity for the progesterone receptor, and virtually no affinity for the mineralocorticoid, estrogen, or androgen receptors. The therapeutic potency of glucocorticoids is related to the half-life of the glucocorticoid-receptor complex. The half-life of the fluticasone propionate-glucocorticoid receptor complex is approximately 10 hours.

Studies performed with CUTIVATE® (fluticasone propionate cream) Cream indicate that it is in the medium range of potency as compared with other topical corticosteroids.

Pharmacokinetics

Absorption

The activity of CUTIVATE® is due to the parent drug, fluticasone propionate. The extent of percutaneous absorption of topical corticosteroids is determined by many factors, including the vehicle and the integrity of the epidermal barrier. Occlusive dressing enhances penetration. Topical corticosteroids can be absorbed from normal intact skin. Inflammation and/or other disease processes in the skin increase percutaneous absorption.

In a human study of 12 healthy males receiving 12.5 g of 0.05% fluticasone propionate cream twice daily for 3 weeks, plasma levels were generally below the level of quantification (0.05 ng/mL). In another study of 6 healthy males administered 25 g of 0.05% fluticasone propionate cream under occlusion for 5 days, plasma levels of fluticasone ranged from 0.07 to 0.39 ng/mL.

In an animal study using radiolabeled 0.05% fluticasone propionate cream and ointment preparations, rats received a topical dose of 1 g/kg for a 24-hour period. Total recovery of radioactivity was approximately 80% at the end of 7 days. The majority of the dose (73%) was recovered from the surface of the application site. Less than 1% of the dose was recovered in the skin at the application site. Approximately 5% of the dose was absorbed systemically through the skin. Absorption from the skin continued for the duration of the study (7 days), indicating a long retention time at the application site.

Distribution

Following intravenous administration of 1 mg fluticasone propionate in healthy volunteers, the initial disposition phase for fluticasone propionate was rapid and consistent with its high lipid solubility and tissue binding. The apparent volume of distribution averaged 4.2 L/kg (range, 2.3 to 16.7 L/kg). The percentage of fluticasone propionate bound to human plasma proteins averaged 91%. Fluticasone propionate is weakly and reversibly bound to erythrocytes. Fluticasone propionate is not significantly bound to human transcortin.

Metabolism

No metabolites of fluticasone propionate were detected in an in vitro study of radiolabeled fluticasone propionate incubated in a human skin homogenate. The total blood clearance of systemically absorbed fluticasone propionate averages 1,093 mL/min (range, 618 to 1,702 mL/min) after a 1-mg intravenous dose, with renal clearance accounting for less than 0.02% of the total. Fluticasone propionate is metabolized in the liver by cytochrome P450 3A4mediated hydrolysis of the 5-fluoromethyl carbothioate grouping. This transformation occurs in 1 metabolic step to produce the inactive17-B-carboxylic acid metabolite, the only known metabolite detected in man. This metabolite has approximately 2,000 times less affinity than the parent drug for the glucocorticoid receptor of human lung cytosol in vitro and negligible pharmacological activity in animal studies. Other metabolites detected in vitro using cultured human hepatoma cells have not been detected in man.

Excretion

Following intravenous dose of 1 mg in healthy volunteers, fluticasone propionate showed polyexponential kinetics and had an average terminal half-life of 7.2 hours (range, 3.2 to 11.2 hours).

Clinical Studies

Psoriasis Studies: In 2 vehicle-controlled studies, CUTIVATE® (fluticasone propionate cream) Cream applied twice daily was significantly more effective than the vehicle in the treatment of moderate to severe psoriasis. The investigator's global evaluation after 28 days of treatment is shown in Table 3.

Table 3: Physician's Assessment of Clinical Response

  CUTIVATE® Cream Vehicle
Study 1
(n = 59)
Study 2
(n = 74)
Study 1
(n = 66)
Study 2
(n = 75)
Cleared 8% 1% 3% 1%
Excellent 29% 28% 11% 17%
Good 27% 34% 20% 28%
Fair 27% 15% 33% 25%
Poor 7% 22% 24% 27%
Worse 2% 0 9% 1%

The clinical signs of psoriasis were scored on a scale of 0 = absent, 1 = mild, 2 = moderate, and 3 = severe. The mean improvements over baseline in the clinical signs at the end of treatment are shown in Table 4.

Table 4: Clinical Signs: Mean Improvements Over Baseline

  CUTIVATE®Cream Vehicle
Study 1 Study 2 Study 1 Study 2
Erythema 1.19 1.07 0.55 0.84
Thickening 1.22 1.17 0.81 0.97
Scaling 1.53 1.39 0.95 1.21

Atopic Dermatitis Studies: In 2 controlled 28-day studies, CUTIVATE® (fluticasone propionate cream) Cream once daily was equivalent to CUTIVATE Cream (fluticasone propionate cream) twice daily in the treatment of moderate to severe eczema. The investigator's global evaluation after 28 days of treatment is shown in Table 5.

Table 5: Physician's Assessment of Clinical Response

  CUTIVATECream
Once Daily
CUTIVATE®Cream
Twice Daily
Study 1
(n = 64)
Study 2
(n = 106)
Study 1
(n = 65)
Study 2
(n = 100)
Cleared 30% 20% 48% 21%
Excellent 42% 32% 32% 50%
Good 17% 26% 5% 12%
Fair 3% 14% 6% 10%
Poor 5% 3% 8% 4%
Worse 3% 6% 2% 3%

The clinical signs and symptoms of atopic dermatitis were scored on a scale of 0 = absent, 1 = mild, 2 = moderate, and 3 = severe. The mean improvements over baseline at the end of treatment are shown in Table 6.

Table 6: Clinical Signs and Symptoms: Mean Improvements Over Baseline

  CUTIVATE®Cream
Once Daily
CUTIVATE® Cream
Twice Daily
Study 1 Study 2 Study 1 Study 2
Erythema 1.7 1.5 1.8 1.7
Pruritus 2.1 1.6 2.1 1.7
Thickening 1.6 1.3 1.6 1.5
Lichenification 1.2 1.2 1.2 1.3
Vesiculation 0.5 0.4 0.5 0.5
Crusting 0.6 0.7 0.8 0.8

Last reviewed on RxList: 9/23/2010
This monograph has been modified to include the generic and brand name in many instances.

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