"A US Food and Drug Administration (FDA) advisory panel has backed a new biologic for psoriasis, though the panelists recommended strong warnings about the potential for suicide and self-injurious behavior (SIB) with the drug.
Effects on Endocrine System
Olux-E (clobetasol propionate foam) Foam has been shown to suppress the HPA axis.
Systemic absorption of Olux-E (clobetasol propionate foam) has caused reversible hypothalamic-pituitary-adrenal (HPA) axis suppression with the potential for clinical glucocorticosteroid insufficiency. This may occur during treatment or upon withdrawal of the topical corticosteroid. Use of Olux-E (clobetasol propionate foam) Foam for longer than 2 weeks may suppress the immune system. [see Nonclinical Toxicology]
In a study including 37 subjects ages 12 and older with at least 30% body surface area (BSA), adrenal suppression was identified in 6 out of 37 subjects (16.2%) after two weeks of treatment with Olux-E. [see CLINICAL PHARMACOLOGY]
Because of the potential for systemic absorption, use of Olux-E (clobetasol propionate foam) may require that patients be periodically evaluated for HPA axis suppression. Factors that predispose a patient using a topical corticosteroid to HPA axis suppression include the use of more potent steroids, use over large surface areas, use over prolonged periods, use under occlusion, use on an altered skin barrier, and use in patients with liver failure.
An ACTH stimulation test may be helpful in evaluating patients for HPA axis suppression. If HPA axis suppression is documented, an attempt should be made to gradually withdraw the drug, to reduce the frequency of application, or to substitute a less potent steroid. Manifestations of adrenal insufficiency may require systemic corticosteroids. Recovery of HPA axis function is generally prompt and complete upon discontinuation of topical corticosteroids.
Cushing's syndrome, hyperglycemia, and unmasking of latent diabetes mellitus can also result from systemic absorption of topical corticosteroids.
Use of more than one corticosteroid-containing product at the same time may increase the total systemic corticosteroid exposure.
Pediatric patients may be more susceptible to systemic toxicity from equivalent doses because of their larger skin surface to body mass ratios. [see Use in Specific Populations]
Local Adverse Reactions with Topical Corticosteroids
Local adverse reactions may be more likely to occur with occlusive use, prolonged use or use of higher potency corticosteroids. Reactions may include atrophy, striae, telangiectasias, burning, itching, irritation, dryness, folliculitis, acneiform eruptions, hypopigmentation, perioral dermatitis, allergic contact dermatitis, secondary infection, and miliaria. Some local adverse reactions may be irreversible.
Allergic contact dermatitis to any component of topical corticosteroids is usually diagnosed by a failure to heal rather than a clinical exacerbation. Clinical diagnosis of allergic contact dermatitis can be confirmed by patch testing.
If irritation develops, treatment with Olux-E (clobetasol propionate foam) Foam should be discontinued and appropriate therapy instituted.
Concomitant Skin Infections
Concomitant skin infections should be treated with an appropriate antimicrobial agent. If the infection persists, Olux-E (clobetasol propionate foam) Foam should be discontinued until the infection has been adequately treated.
The propellant in Olux-E (clobetasol propionate foam) Foam is flammable. Avoid fire, flame or smoking during and immediately following application. Do not puncture and/or incinerate the containers. Do not expose containers to heat and/or store at temperatures above 120°F (49°C).
Patient Counseling Information
[See FDA-Approved Patient Labeling]
Patients using topical corticosteroids should receive the following information and instructions:
- This medication is to be used as directed by the physician. It is for external use only. Unless directed by the prescriber, it should not be used on the face, or in skin-fold areas, such as the underarms or groin. Avoid contact with the eyes or other mucous membranes. Wash hands after use.
- This medication should not be used for any disorder other than that for which it was prescribed.
- The treated skin area should not be bandaged, wrapped, or otherwise covered so as to be occlusive unless directed by the physician.
- Patients should report any signs of local or systemic adverse reactions to the physician.
- Patients should inform their physicians that they are using Olux-E (clobetasol propionate foam) Foam if surgery is contemplated.
- As with other corticosteroids, therapy should be discontinued when control is achieved. If no improvement is seen within 2 weeks, contact the physician.
- Patients should not use more than 50 grams per week of Olux-E (clobetasol propionate foam) Foam, or an amount greater than 21 capfuls per week. [see DOSAGE AND ADMINISTRATION]
- This medication is flammable; avoid heat, flame or smoking when applying this product.
Carcinogenesis, Mutagenesis, Impairment of Fertility
Long-term animal studies have not been performed to evaluate the carcinogenic potential of Olux-E Foam or clobetasol propionate. In a 90-day repeat-dose toxicity study in rats, topical administration of Olux-E (clobetasol propionate foam) Foam at dose concentrations from 0.001 – 0.1% or from 0.03 to 0.3 mg/kg/day of clobetasol propionate resulted in a toxicity profile consistent with long term exposure to corticosteroids including adrenal atrophy, histopathological changes in several organs systems indicative of severe immune suppression and opportunistic fungal and bacterial infections. A NOAEL could not be determined in this study. Although the clinical relevance of the findings in animals to humans is not clear, sustained glucocorticoid-related immune suppression may increase the risk of infection and possibly the risk for carcinogenesis.
Clobetasol propionate was non-mutagenic in four different test systems: the Ames test, the mouse lymphoma test, the Saccharomyces cerevisiae gene conversion assay, and the E. coli B WP2 fluctuation test. In the in vivo mouse micronucleus test, a positive finding was observed at 24 hours, but not at 48 hours, following oral administration at a dose of 2000 mg/kg.
Studies in the rat following subcutaneous administration of clobetasol propionate at dosage levels up to 0.05 mg/kg per day revealed that the females exhibited an increase in the number of resorbed embryos and a decrease in the number of living fetuses at the highest dose.
Use In Specific Populations
Teratogenic Effects, Pregnancy Category C
There are no adequate and well-controlled studies of the teratogenic potential of clobetasol propionate in pregnant women. Olux-E (clobetasol propionate foam) Foam should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
Corticosteroids have been shown to be teratogenic in laboratory animals when administered systemically at relatively low dosage levels. Some corticosteroids have been shown to be teratogenic after dermal application to laboratory animals.
Clobetasol propionate has not been tested for teratogenicity when applied topically; however, it is absorbed percutaneously, and when administered subcutaneously, it was a significant teratogen in both the rabbit and the mouse. Clobetasol propionate has greater teratogenic potential than steroids that are less potent.
Teratogenicity studies in mice using the subcutaneous route resulted in fetotoxicity at the highest dose tested (1 mg/kg) and teratogenicity at all dose levels tested down to 0.03 mg/kg. These doses are approximately 1.4 and 0.04 times, respectively, the human topical dose of Olux-E (clobetasol propionate foam) Foam based on body surface area comparisons. Abnormalities seen included cleft palate and skeletal abnormalities.
In rabbits, clobetasol propionate was teratogenic at doses of 0.003 and 0.01 mg/kg. These doses are approximately 0.02 and 0.05 times, respectively, the human topical dose of Olux-E (clobetasol propionate foam) Foam based on body surface area comparisons. Abnormalities seen included cleft palate, cranioschisis, and other skeletal abnormalities.
Systemically administered corticosteroids appear in human milk and could suppress growth, interfere with endogenous corticosteroid production, or cause other untoward effects. It is not known whether topical administration of corticosteroids could result in sufficient systemic absorption to produce detectable quantities in breast milk. Because many drugs are excreted in human milk, caution should be exercised when Olux-E (clobetasol propionate foam) Foam is administered to a nursing woman.
If used during lactation, Olux-E (clobetasol propionate foam) Foam should not be applied on the chest to avoid accidental ingestion by the infant.
Use in pediatric patients under 12 years of age is not recommended because of the risk of HPA axis suppression.
After two weeks of twice daily treatment with Olux-E (clobetasol propionate foam) Foam, 7 of 15 patients (47%) aged 6 to 11 years of age demonstrated HPA axis suppression. The laboratory suppression was transient; in all subjects serum cortisol levels returned to normal when tested 4 weeks post treatment.
In 92 patients from 12 to 17 years of age, safety was similar to that observed in the adult population. Based on these data, no adjustment of dosage of Olux-E (clobetasol propionate foam) Foam in adolescent patients 12 to 17 years of age is warranted.
Because of a higher ratio of skin surface area to body mass, pediatric patients are at a greater risk than adults of HPA axis suppression and Cushing's syndrome when they are treated with topical corticosteroids. They are therefore also at greater risk of adrenal insufficiency during and/or after withdrawal of treatment.
HPA axis suppression, Cushing's syndrome, linear growth retardation, delayed weight gain, and intracranial hypertension have been reported in children receiving topical corticosteroids. Manifestations of adrenal suppression in children include low plasma cortisol levels and an absence of response to ACTH stimulation. Manifestations of intracranial hypertension include bulging fontanelles (in infants), headaches, and bilateral papilledema. Administration of topical corticosteroids to children should be limited to the least amount compatible with an effective therapeutic regimen. Chronic corticosteroid therapy may interfere with the growth and development of children.
Adverse effects including striae have been reported with inappropriate use of topical corticosteroids in infants and children.
A limited number of patients at or above 65 years of age have been treated with Olux-E (clobetasol propionate foam) Foam (n = 58) in US clinical trials. While the number of patients is too small to permit separate analysis of efficacy and safety, the adverse reactions reported in this population were similar to those reported by younger patients. Based on available data, no adjustment of dosage of Olux-E (clobetasol propionate foam) Foam in geriatric patients is warranted.This monograph has been modified to include the generic and brand name in many instances.
Last reviewed on RxList: 12/16/2010
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