Nefecon Special Precautions

Hypercorticism and adrenal axis suppression: When glucocorticosteroids are used chronically, systemic effects such as hypercorticism and adrenal suppression may occur. Glucocorticosteroids can reduce the response of the hypothalamus-pituitary-adrenal (HPA) axis to stress. In situations where patients are subject to surgery or other stress situations, supplementation with a systemic glucocorticosteroid is recommended.
Since Nefecon contains a glucocorticosteroid, general warnings concerning glucocorticosteroids, as given as follows, should be followed.
Hepatic impairment: Patients with moderate or severe hepatic impairment (Child-Pugh Class B or C respectively) could be at an increased risk of hypercorticism and adrenal axis suppression due to an increased systemic exposure of oral budesonide. Patients with moderate hepatic impairment (Child-Pugh Class B) should be monitored for increased signs and/or symptoms of hypercorticism.
Symptoms of steroid withdrawal in patients transferred from systemic corticosteroids: Patients who are transferred from glucocorticosteroid treatment with high systemic availability to glucocorticosteroids with lower systemic availability, such as budesonide, should be monitored since symptoms attributed to withdrawal of steroid therapy, including those of acute adrenal axis suppression or benign intracranial hypertension, may develop. Adrenocortical function monitoring may be required in these patients and the dose of glucocorticosteroid treatment with high systemic effects should be reduced cautiously.
Replacement of systemic glucocorticosteroids with budesonide may unmask allergies (e.g., rhinitis and eczema), which were previously controlled by the systemic medicinal product.
Infections: Patients who are on medicinal products that suppress the immune system are more susceptible to infection than healthy individuals. Chickenpox and measles, for example, can have a more serious or even fatal course in susceptible patients or patients on immunosuppressant doses of glucocorticosteroids. In patients who have not had these diseases, particular care should be taken to avoid exposure.
How the dose, route, and duration of glucocorticosteroid administration affect the risk of developing a disseminated infection is not known. The contribution of the underlying disease and/or prior glucocorticosteroid treatment to the risk is also not known. If exposed to chickenpox, therapy with varicella zoster immune globulin (VZIG) or pooled intravenous immunoglobulin (IVIG), as appropriate, may be indicated. If exposed to measles, prophylaxis with pooled intramuscular immunoglobulin (IG) may be indicated. (See Summaries of Product Characteristics for VZIG and IG.) If chickenpox develops, treatment with antiviral agents may be considered.
Glucocorticosteroids should be used with caution, if at all, in patients with active or quiescent tuberculosis infection, untreated fungal, bacterial, systemic viral or parasitic infections, or ocular herpes simplex.
Caution with special diseases: Patients with infections, hypertension, diabetes mellitus, osteoporosis, peptic ulcer, glaucoma or cataracts, or with a family history of diabetes or glaucoma, or with any other condition where use of glucocorticosteroids may be associated with an increased risk of adverse effects, should be monitored.
Visual disturbance: Visual disturbance may be reported with systemic and topical glucocorticosteroid use. If a patient presents with symptoms such as blurred vision or other visual disturbances, the patient should be considered for referral to an ophthalmologist for evaluation of possible causes which may include cataract, glaucoma or rare diseases such as central serous chorioretinopathy (CSCR) which have been reported after use of systemic and topical glucocorticosteroids.
Concomitant treatment with potent CYP3A4 inhibitors: Concomitant treatment with potent CYP3A4 inhibitors, including ketoconazole and cobicistat-containing products, is expected to increase the risk of systemic side effects attributable to budesonide. The combination should be avoided unless the benefit outweighs the increased risk of systemic glucocorticosteroid side effects. If this is not possible, the period between treatments should be as long as possible and a reduction of the budesonide dose to 8 mg budesonide daily could also be considered (see Interactions).
After extensive intake of grapefruit juice (which inhibits CYP3A4 activity predominantly in the intestinal mucosa), the systemic exposure to budesonide after oral administration increased approximately two-fold. As with other medicinal products primarily metabolised through CYP3A4, regular ingestion of grapefruit or its juice should be avoided in connection with Nefecon administration (other juices such as orange juice or apple juice do not inhibit CYP3A4). See also Interactions.
ACTH stimulation test: Because adrenal function may be suppressed, an ACTH stimulation test for diagnosing pituitary insufficiency might show false results (low values).
Sucrose: Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrose-isomaltase insufficiency should not take this medicinal product.
Effects on ability to drive and use machines: No studies on the effects of Nefecon on the ability to drive and use machines have been performed. It is expected that Nefecon has no or negligible influence on the ability to drive or use machinery.