BETAMETHASONE 17-VALERATE

TITLE

Betamethasone 17-valerate

SCOPE

Tradenames

The tradenames for this product include

BETNOVATE™

Formulations and Strengths

Cream, Ointment

Contains 0.122% w/w betamethasone 17-valerate.

Ready Diluted Cream and Ointment

Contains 0.025% w/w betamethasone as betamethasone 17-valerate.

Excipients

It is mandatory for country product information to include both the complete list of
excipients for all locally marketed presentations, and any locally imposed
excipient warning statements.

Cream

Chlorocresol
Macrogol cetostearyl ether
Cetostearyl alcohol
White soft paraffin
Liquid paraffin
Sodium dihydrogen phosphate dihydrate
Phosphoric acid
Sodium hydroxide
Purified water

Ointment

Liquid paraffin
White soft paraffin
CLINICAL INFORMATION

Indications

Cream, Ointment

Betamethasone valerate is a potent topical corticosteroid indicated for adults,

elderly and children over 1 year for the relief of the inflammatory and pruritic
manifestations of steroid responsive dermatoses. These include the following:

Atopic dermatitis (including infantile atopic dermatitis)

Nummular dermatitis (discoid eczema)

Prurigo nodularis

Psoriasis (excluding widespread plaque psoriasis)

Lichen simplex chronicus (neurodermatitis) and lichen planus

Seborrhoeic dermatitis

Irritant or allergic contact dermatitis

Discoid lupus erythematosus

Adjunct to systemic steroid therapy in generalised erythroderma

Insect bite reactions

Miliaria (prickly heat)

Dosage and Administration

Adults, Elderly and Children over 1 year

Cream

Creams are especially appropriate for moist or weeping surfaces.

Ointment

Ointments are especially appropriate for dry, lichenified or scaly lesions.

Ointment, Cream
Apply thinly and gently rub in using only enough to cover the entire affected area
once or twice daily for up to 4 weeks until improvement occurs, then reduce the
frequency of application or change the treatment to a less potent preparation.
Allow adequate time for absorption after each application before applying an
emollient.

In the more resistant lesions, such as the thickened plaques of psoriasis on

elbows and knees, the effect of betamethasone valerate can be enhanced, if
necessary, by occluding the treatment area with polythene film. Overnight
occlusion only is usually adequate to bring about a satisfactory response in such
lesions; thereafter, improvement can usually be maintained by regular application
without occlusion.

If the condition worsens or does not improve within 2-4 weeks, treatment and
diagnosis should be re-evaluated.

Atopic dermatitis (eczema)

Therapy with betamethasone valerate should be gradually discontinued once

control is achieved and an emollient continued as maintenance therapy.

Rebound of pre-existing dermatoses can occur with abrupt discontinuation of

betamethasone valerate.

Cream, Ointment

Recalcitrant dermatoses

Patients who frequently relapse

Once an acute episode has been treated effectively with a continuous course of
topical corticosteroid, intermittent dosing (once daily, twice weekly, without
occlusion) may be considered. This has been shown to be helpful in reducing the
frequency of relapse.

Application should be continued to all previously affected sites or to known sites

of potential relapse. This regime should be combined with routine daily use of
emollients. The condition and the benefits and risks of continued treatment must
be re-evaluated on a regular basis.

All Formulations

Children

Betamethasone valerate is contraindicated in children under one year of age.

Children are more likely to develop local and systemic side effects of topical
corticosteroids and, in general, require shorter courses and less potent agents
than adults.
Care should be taken when using betamethasone valerate to ensure the amount
applied is the minimum that provides therapeutic benefit.

Elderly

Clinical studies have not identified differences in responses between the elderly
and younger patients. The greater frequency of decreased hepatic or renal
function in the elderly may delay elimination if systemic absorption occurs.
Therefore the minimum quantity should be used for the shortest duration to
achieve the desired clinical benefit.

Renal / Hepatic Impairment

In case of systemic absorption (when application is over a large surface area for
a prolonged period) metabolism and elimination may be delayed therefore
increasing the risk of systemic toxicity. Therefore the minimum quantity should be
used for the shortest duration to achieve the desired clinical benefit.

Contraindications

Cream, Ointment

The following conditions should not be treated with betamethasone valerate:

• Untreated cutaneous infections

• Rosacea

• Acne vulgaris

• Pruritus without inflammation

• Perianal and genital pruritus

• Perioral dermatitis

All Formulations

Betamethasone valerate is contraindicated in dermatoses in infants under one

year of age, including dermatitis.

Warnings and Precautions

Betamethasone valerate should be used with caution in patients with a history of

local hypersensitivity to corticosteroids or to any of the excipients in the
preparation. Local hypersensitivity reactions (see Adverse Reactions) may
resemble symptoms of the condition under treatment.

Manifestations of hypercortisolism (Cushing’s syndrome) and reversible

hypothalamic-pituitary-adrenal (HPA) axis suppression, leading to
glucocorticosteroid insufficiency, can occur in some individuals as a result of
increased systemic absorption of topical steroids. If either of the above are
observed, withdraw the drug gradually by reducing the frequency of application,
or by substituting a less potent corticosteroid. Abrupt withdrawal of treatment may
result in glucocorticosteroid insufficiency (see Adverse Reactions).

Risk factors for increased systemic effects are:

• Potency and formulation of topical steroid

• Duration of exposure

• Application to a large surface area

• Use on occluded areas of skin (e.g. on intertriginous areas or under occlusive

dressings (in infants the nappy may act as an occlusive dressing)

• Increasing hydration of the stratum corneum

• Use on thin skin areas such as the face

• Use on broken skin or other conditions where the skin barrier may be
impaired

• In comparison with adults, children may absorb proportionally larger amounts

of topical corticosteroids and thus be more susceptible to systemic adverse
effects. This is because children have an immature skin barrier and a greater
surface area to body weight ratio compared with adults.

Children

In infants and children under 12 years of age, long-term continuous topical

corticosteroid therapy should be avoided where possible, as adrenal suppression
can occur.

Infection risk with occlusion

Bacterial infection is encouraged by the warm, moist conditions within skin folds
or caused by occlusive dressings. When using occlusive dressings, the skin
should be cleansed before a fresh dressing is applied.

Use in Psoriasis

Topical corticosteroids should be used with caution in psoriasis as rebound

relapses, development of tolerances, risk of generalised pustular psoriasis and
development of local or systemic toxicity due to impaired barrier function of the
skin have been reported in some cases. If used in psoriasis careful patient
supervision is important.
Cream, Ointment

Application to the face

Prolonged application to the face is undesirable as this area is more susceptible

to atrophic changes

Application to the eyelids

If applied to the eyelids, care is needed to ensure that the preparation does not
enter the eye, as cataract and glaucoma might result from repeated exposure.

Concomitant infection

Appropriate antimicrobial therapy should be used whenever treating inflammatory

lesions which have become infected. Any spread of infection requires withdrawal
of topical corticosteroid therapy and administration of appropriate antimicrobial
therapy.

Chronic leg ulcers

Topical corticosteroids are sometimes used to treat the dermatitis around chronic
leg ulcers. However, this use may be associated with a higher occurrence of local
hypersensitivity reactions and an increased risk of local infection.

Interactions for both formulations

Co-administered drugs that can inhibit CYP3A4 (e.g. ritonavir, itraconazole) have
been shown to inhibit the metabolism of corticosteroids leading to increased
systemic exposure. The extent to which this interaction is clinically relevant
depends on the dose and route of administration of the corticosteroids and the
potency of the CYP3A4 inhibitor.

Pregnancy and Lactation

Fertility

There are no data in humans to evaluate the effect of topical corticosteroids on

fertility.

Pregnancy

There are limited data from the use of betamethasone valerate in pregnant
women.

Topical administration of corticosteroids to pregnant animals can cause

abnormalities of foetal development (see Non-clinical Information).
The relevance of this finding to humans has not been established; however,
administration of betamethasone valerate during pregnancy should only be
considered if the expected benefit to the mother outweighs the risk to the foetus.
The minimum quantity should be used for the minimum duration.

Lactation

The safe use of topical corticosteroids during lactation has not been established.

It is not known whether topical administration of corticosteroids could result in

sufficient systemic absorption to produce detectable amounts in breast milk.
Administration of betamethasone valerate during lactation should only be
considered if the expected benefit to the mother outweighs the risk to the infant.

If used during lactation betamethasone valerate should not be applied to the

breasts to avoid accidental ingestion by the infant.

Ability to perform tasks that require judgement, motor or cognitive skills

There have been no studies to investigate the effect of betamethasone valerate

on driving performance or the ability to operate machinery. A detrimental effect
on such activities would not be anticipated from the adverse reaction profile of
topical betamethasone valerate.

Adverse Reactions

Adverse drug reactions (ADRs) are listed below by MedDRA system organ class
and by frequency. Frequencies are defined as: very common (≥1/10), common
(≥1/100 and <1/10), uncommon (≥1/1,000 and <1/100), rare (≥1/10,000 and
<1/1,000) and very rare (<1/10,000), including isolated reports.

Post-marketing data

Infections and Infestations

Very rare Opportunistic infection

Immune System Disorders

Very rare Local hypersensitivity

Endocrine Disorders

Very rare Hypothalamic-pituitary adrenal (HPA) axis

suppression Cushingoid features (e.g. moon face,
central obesity), delayed weight gain/growth
retardation in children, osteoporosis, glaucoma,
hyperglycaemia/glucosuria, cataract, hypertension,
increased weight/obesity, decreased endogenous
cortisol levels, alopecia, trichorrhexis
Skin and Subcutaneous Tissue Disorders

Common Pruritus, local skin burning/skin pain

Very rare Allergic contact dermatitis/dermatitis, erythema, rash,

urticaria, pustular psoriasis, skin thinning*/skin
atrophy*, skin wrinkling*, skin dryness*, striae*,
telangiectasias*, pigmentation changes*,
hypertrichosis, exacerbation of underlying symptoms

General Disorders and Administration Site Conditions

Very rare Application site irritation/pain

*Skin features secondary to local and/or systemic effects of hypothalamic-

pituitary adrenal (HPA) axis suppression.

Overdosage

Symptoms and signs

Topically applied betamethasone valerate may be absorbed in sufficient amounts

to produce systemic effects. Acute overdosage is very unlikely to occur, however,
in the case of chronic overdosage or misuse the features of hypercortisolism may
occur (see Adverse Reactions).

Treatment

In the event of overdose, betamethasone valerate should be withdrawn gradually

by reducing the frequency of application, or by substituting a less potent
corticosteroid because of the risk of glucocorticosteroid insufficiency.

Further management should be as clinically indicated or as recommended by the

national poisons centre, where available.

Clinical Pharmacology

Pharmacodynamics

ATC code

D07AC Corticosteroids, potent (group III)

Mechanism of action

Topical corticosteroids act as anti-inflammatory agents via multiple mechanisms

to inhibit late phase allergic reactions including decreasing the density of mast
cells, decreasing chemotaxis and activation of eosinophils, decreasing cytokine
production by lymphocytes, monocytes, mast cells and eosinophils, and inhibiting
the metabolism of arachidonic acid.

Pharmacodynamic effects

Topical corticosteroids have anti-inflammatory, antipruritic, and vasoconstrictive

properties.

Pharmacokinetics

Absorption

Topical corticosteroids can be systemically absorbed from intact healthy skin.

The extent of percutaneous absorption of topical corticosteroids is determined by
many factors, including the vehicle and the integrity of the epidermal barrier.
Occlusion, inflammation and/or other disease processes in the skin may also
increase percutaneous absorption.

Distribution

The use of pharmacodynamic endpoints for assessing the systemic exposure of

topical corticosteroids is necessary because circulating levels are well below the
level of detection.

Metabolism

Once absorbed through the skin, topical corticosteroids are handled through
pharmacokinetic pathways similar to systemically administered corticosteroids.
They are metabolised, primarily in the liver.

Elimination

Topical corticosteroids are excreted by the kidneys. In addition, some

corticosteroids and their metabolites are also excreted in the bile.

Clinical studies

NON-CLINICAL INFORMATION

Carcinogenesis / Mutagenesis

Carcinogenesis
Long-term animal studies have not been performed to evaluate the carcinogenic
potential of betamethasone valerate.
Genotoxicity
No specific studies have been conducted to investigate the genotoxic potential of
betamethasone valerate.

Fertility
The effect on fertility of betamethasone valerate has not been evaluated in
animals.

Pregnancy
Subcutaneous administration of betamethasone valerate to mice or rats at doses
≥0.1 mg/kg/day or rabbits at doses ≥12 micrograms/kg/day during pregnancy
produced foetal abnormalities including cleft palate.

PHARMACEUTICAL INFORMATION

Shelf-life

Cream : 24 months when stored below 30C

36 months when stored below 25C

Ointment : 36 months

Storage

Cream : Store below 25C (36 months shelf life)

Store below 30C (24 months shelf life)

Ointment : Store below 30°C

Nature and contents of container

Cream

Collapsible aluminium tubes internally coated with an epoxy resin based lacquer
and closed with a cap.

Opaque high density polythene pots with black urea formaldehyde screw caps
having a steran faced wad.

Ointment
Collapsible aluminium tubes internally coated with an epoxy resin based lacquer
and closed with a cap.

Polypropylene/polyethylene pump dispenser with natural (translucent)

polypropylene body. The nozzle is sealed with a polyethylene acetyl tab. The
pump is closed with an opaque polypropylene overcap and overwrapped with an
opaque shrink-wrap.

Use and handling

There are no special requirements for use or handling of this product.

GSK is committed to the effective collection and management of human safety

information relating to our products and we encourage healthcare professionals to
report adverse events to us on +255 764 769961 or email us on [email protected]

Full Prescribing Information is available on request from GlaxoSmithKline

Pharmaceutical Kenya Limited, P.O. Box 78392-00507, 23 Likoni Road, Industrial Area,
Nairobi, Kenya

Full Prescribing Information prepared in July 2017 based on GDS version 08 dated 13
September 2013.