natgillin/translations-raw huggingface dataset:
Det vedgås også, at begrænsningerne og usikkerhederne ved datasættet står i vejen for at drage holdbare konklusioner om virkningen.
It is recognised also that the limitations and uncertainties attached to the dataset hinder the ability to draw robust conclusions on the efficacy.
Samlet konklusion og begrundelse for PRAC's reviderede anbefaling Ud fra følgende betragtninger:
Overall conclusion and grounds for the revised PRAC recommendation
De kliniske undersøgelser, der er udført under udviklingen af bromhexin og lægemidler indeholdende ambroxol mellem 1950'erne og 1980'erne, var væsentligt mindre standardiserede, end det ville være nødvendigt i dag, og ville ikke fuldstændig opfylde nutidige krav om validerede endepunkter, statistisk bekræftelse eller god klinisk praksis (GCP).
The clinical studies performed during the development of bromhexine- and ambroxol-containing products between the 1950ies and 1980ies were considerably less standardised than would be necessary today, and would not completely fulfil contemporary requirements with regard to validated endpoints, statistical confirmation, or Good Clinical Practice (GCP).
Af indberetningernes datering fremgår det imidlertid, at 40 af de i alt 119 indberetninger, der er foretaget for det oprindelige lægemiddel siden første markedsføringstilladelse, synes at være sendt i to sæt af de kinesiske sundhedsmyndigheder til indehaveren af markedsføringstilladelsen for det oprindelige lægemiddel.
However, when looking at the date of the reports, 40 reports, out of the 119 reported in total for the originator since the first marketing authorisation, appear to have been sent in two batches by the Chinese health authority to the MAH of the originator of these products.
Derudover anbefalede PRAC harmonisering af begreberne vedrørende hypersensitivitetsreaktioner i produktinformationen.
In addition the PRAC recommended harmonising the terms related to hypersensitivity reactions in the product information.
Endvidere bør tilfælde af SCAR analyseres nærmere i fremtidige PSUR'er.
Moreover SCARs cases should be analysed in details in future PSURs.
Den samlede indberetningsfrekvens er imidlertid meget lav i betragtning af den skønnede eksponering, og der er i disse tilfælde mange konfunderende faktorer til stede, hvorfor evidensen for denne risiko er svag.
However, the overall reporting rate is very low when the estimated exposure is considered and many confounders are present in these cases, the evidence supporting this risk is therefore weak.
Mange patienter med SCAR får forskellige mucolytiske eller sekretolytiske midler i det relevante tidsrum før indsætten af bivirkningen.
Many patients with SCARs receive various mucolytic or secretolytic agents in the relevant time period before the onset of their adverse event.
I undersøgelser af luftvejssygdomme ses ofte en stor placebovirkning, navnlig ved ikke-alvorlige, selvbegrænsende sygdomme.
Often a large placebo effect is seen in studies investigating respiratory conditions, particularly in non-serious, self-limiting conditions.
Som følge heraf tilfører de undersøgelser, der er udført efter den oprindelige markedsføringstilladelse, ikke nye videnskabelige data af betydning for virkningen af produkterne.
For these reasons studies conducted after the initial marketing authorisation do not provide new significant scientific data on the efficacy of the products.
Der burde imidlertid indføres kortere mellemrum mellem PSUR'er for jævnligt at fortsætte gennemgangen af data, der bliver til rådighed om produkternes benefit/risk-forhold.
However, a shorter PSUR cycle should be introduced to continue to review periodically data that becomes available on the benefit-risk balance of the products.
I nogle undersøgelser kunne der ikke påvises signifikant forskel mellem ambroxol eller bromhexin og placebo, og i andre var der kun signifikant forskel i nogle af de undersøgte endepunkter.
Some trials failed to show a significant difference between ambroxol or bromhexine and placebo and other only showed significant difference in some of the studied endpoints.
Det må bemærkes, at hvis patienten er sat i behandling med det pågældende lægemiddel mindre end 4 dage før eller mere end 8 uger før indsætten af reaktionen, er det usandsynligt, at lægemidlet er årsag.
Of note, drugs started less than 4 days or more than 8 weeks before the onset of the reaction are unlikely to be responsible.
Fire tilfælde af SCAR, der er hentet i EudraVigilance, og tre andre fra litteraturen er blevet vurderet til at have sammenhæng med ambroxol.
Four cases of SCARs retrieved from Eudravigilance and 3 others from the literature have been assessed as related to ambroxol.
• PRAC tog stilling til proceduren i medfør af artikel 31 i direktiv 2001/83/EF, der var foranlediget af lægemiddelovervågningsdata for produkter indeholdende ambroxol og bromhexin
• The PRAC considered the procedure under Article 31 of Directive 2001/83/EC resulting from pharmacovigilance data for ambroxol- and bromhexine-containing medicinal products.
I betragtning af disse begrænsninger og den svage evidens for et sikkerhedsproblem baseret på lægemiddelovervågningsdata kunne PRAC imidlertid ikke af den foreliggende evidens konkludere, at risiciene oversteg fordelene ved de forskellige indikationer.
Taking into account these limitations, together with the weak evidence of a safety issue from the pharmacovigilance data, the PRAC could not conclude from the available evidence that risks outweighed benefits in the different indications.
PRAC konkluderede derfor, at den foreliggende evidens ikke berettigede indførelse af yderligere aldersspecifikke begrænsninger i produktinformationen.
Therefore the PRAC concluded that the evidence available did not justify the introduction of further age specific restrictions in the product information.
Efter gennemgang af PRAC's anbefaling dateret 9. januar 2015 vedtog CMDh den 25. februar 2015 ved en flertalsafgørelse en udtalelse om, at markedsføringstilladelserne for de omfattede lægemidler burde ændres.
On 25 February 2015, the CMDh, having considered the PRAC recommendation, dated 9 January 2015, reached by majority the position that the marketing authorisations for the concerned medicinal products should be varied.
PRAC tog hensyn til bemærkningen fra det pædiatriske udvalg (PDCO) om, at anvendelsen af ambroxol og bromhexin varierer væsentligt i pædiatrisk klinisk praksis i EU.
The PRAC took note of the advice of the paediatric committee (PDCO) that the use of ambroxol and bromhexine varies significantly in paediatric clinical practice across the EU.
CMDh tog hensyn til PRAC's anbefaling om, at den foreliggende evidens ikke gav tilstrækkeligt grundlag for at påvise en ændring i det fastlagte benefit/risk-forhold, forudsat at der foretages de anbefalede ændringer af produktinformationens afsnit 4.4 og 4.8 som beskrevet i bilag III.
The CMDh considered the PRAC recommendation that the evidence available did not provide sufficient grounds to demonstrate a change to the established benefit-risk balance, provided the recommended amendments to sections 4.4 and 4.8 of the product information, detailed in annex III, are implemented.
Der blev dog beskrevet beskedne, men positive resultater for ambroxol og bromhexin.
Nevertheless, modest but positive results were reported for ambroxol and bromhexine.
Spørgsmål vedrørende virkning
Efficacy issues
Stigningen i indberetninger følger efter at der er indført nye bestemmelser om lægemiddelovervågning i Kina, hvilket kan have påvirket bivirkningsindberetningen og ikke afspejler nye sikkerhedsproblemer.
This increase in reporting follows the implementation of a new pharmacovigilance regulation in China that might have influenced adverse reaction reporting and does not reflect a new safety concern.
I 2012-2014 blev der iagttaget en stigning i indberetningsfrekvensen for anafylaktiske reaktioner med sammenhæng med ambroxol.
An increase was observed in the reporting frequency of anaphylactic reactions over 2012-2014 linked to ambroxol.
Da ambroxol er en metabolit af bromhexin, og da hypersensitivitetsreaktioner ikke afhænger af dosis af det absorberede allergene stof, fandt FAMHP, at enhver bekræftet risiko for sådanne reaktioner med ambroxol også ville gøre sig gældende for lægemidler indeholdende bromhexin.
As ambroxol is a metabolite of bromhexine and hypersensitivity reactions are not dependent on the dose of the allergenic substance absorbed, the FAMHP considered that any confirmed risk with ambroxol could also be found in bromhexine-containing medicinal products with regards to these reactions.
Efter at have vurderet en PSUR omfattet af arbejdsdelingsproceduren for lægemidler indeholdende ambroxol, som blev påbegyndt i januar 2012, opfølgende indsendelser og aktiviteter til signaldetektion konstaterede de kompetente belgiske nationale myndigheder (FAMHP) en stigning i indberetningerne af hypersensitivitetsreaktioner i årene 2012-2014, indberetninger om svære kutane bivirkninger (SCAR), og en benefit/risk-vurdering for børn under seks år, hvori det konkluderedes, at der ikke var tegn på, at sikkerhedsprofilen var anderledes, men at der ikke var tilstrækkelig evidens for virkningen til sekretolytisk behandling hos denne aldersgruppe, og at benefit/risk-forholdet derfor var negativt.
Further to the evaluation of a Worksharing PSUR of ambroxol-containing medicinal products started in January 2012 and of follow-up submissions as well as signal detection activities, the Belgian national competent authority (FAMHP) identified an increase in reporting of hypersensitivity reactions over the years 2012-2014, reports of severe cutaneous adverse reactions (SCARs) and a benefit-risk evaluation in children below 6 years of age concluded that while there was no indication of a different safety profile, insufficient evidence of efficacy was available in secretolytic therapy in this age group, leading to a negative benefit-risk balance.
På denne baggrund foretog FAMHP den 4. april 2014 en indbringelse for Det Europæiske Lægemiddelagentur med anmodning om, at PRAC fremsatte en anbefaling i medfør af artikel 31 i direktiv 2001/83/EF om, hvorvidt benefit/risk-forholdet for disse produkter fortsat er positivt til de godkendte indikationer, og om markedsføringstilladelserne for produkter indeholdende ambroxol bør opretholdes, ændres, suspenderes eller inddrages.
In light of the above, on 4 April 2014, the FAMHP informed the European Medicines Agency, of their decision to notify a referral procedure to ask for the PRAC's recommendation pursuant to Article 31 of Directive 2001/83/EC, on whether the balance of benefits and risks for these products is still positive in the approved indications, and whether the marketing authorisations for ambroxol- and bromhexinecontaining medicinal products should be maintained, varied, suspended or withdrawn.
PRAC gennemgik alle de indsendte data vedrørende sikkerheden og virkningen af lægemidlerne for at vurdere den potentielle virkning af de nye sikkerhedsmæssige betænkeligheder vedrørende det fastlagte benefit/risk-forhold for de godkendte lægemidler.
All the available data submitted, related to the safety and the efficacy of the medicinal products were reviewed by the PRAC to assess the potential impact of the new safety concerns identified on the established benefit-risk balance of the authorised medicinal products.
PRAC bemærkede dog, at den iagttagne stigning i indberetninger af anafylaktiske reaktioner for produkter indeholdende ambroxol måtte antages at være et artefakt, der skyldtes nye bestemmelser om lægemiddelovervågning i Kina og ikke udgjorde et nyt sikkerhedsproblem.
The PRAC however noted that the observed increase in reporting of anaphylactic reactions for ambroxol-containing products was likely an artefact resulting from the implementation of a new pharmacovigilance regulation in China and did not constitute a new safety concern.
• PRAC var af den opfattelse, at risikoen for SCAR bør håndteres ved, at den nævnes i produktinformationen ledsaget af en advarsel, der gør patienter og omsorgsgivere opmærksomme på prodromerne til SCAR med henblik på øjeblikkelig seponering af behandlingen hvis sådanne tegn optræder
• The PRAC was of the view that the risk of SCARs should be addressed by its inclusion in the product information accompanied by a warning in order for patients and caregivers to recognise the prodromes of SCARs and discontinue treatment immediately in the event of such signs.
• PRAC gennemgik samtlige indsendte data vedrørende sikkerheden og virkningen af produkter indeholdende ambroxol og bromhexin, herunder materiale indsendt af indehaverne af markedsføringstilladelsesindehaverne og ekspertbidrag
• The PRAC reviewed the totality of the data submitted in support of the safety and efficacy of ambroxol- and bromhexine-containing products, including submissions from the marketing authorisation holders and expert input.
Sikkerhedsoplysningerne fra indehaverne af markedsføringstilladelse, fra EudraVigilance og fra litteraturen omfatter i alt omkring 300 case-rapporter om formodede SCAR, hvor der i mange tilfælde kan have været konfunderende faktorer.
The safety information submitted by the MAHs, from Eudravigilance and from the literature, comprises in total around 300 case reports of suspected SCARs, many of which have possible confounders.
Ambroxol og bromhexin er i nogle medlemsstater desuden godkendt til luftvejssygdomme i fast kombination med forskellige aktive stoffer.
In addition, ambroxol and bromhexine have been approved in some EU MS in airway diseases indications in fixed dose combinations with various active substances.
Efter gennemgang af PRAC's reviderede anbefaling tilslutter CMDh sig PRAC's overordnede videnskabelige konklusioner og nåede til den opfattelse, at markedsføringstilladelserne for lægemidler indeholdende ambroxol- og bromhexin bør ændres.
The CMDh, having considered the revised PRAC recommendation, agrees with the overall scientific conclusions by the PRAC and reached the position that the marketing authorisations for ambroxol- and bromhexine-containing medicinal products should be varied.
PRAC tog alle disse elementer i betragtning i sin gennemgang af de foreliggende data om virkningen af produkter indeholdende ambroxol og bromhexin.
The PRAC considered all these elements in its review of the available data on the efficacy of ambroxol- and bromhexine-containing products.
Hypersensitivitetsreaktioner er uafhængige af dosis og formulering, hvorfor den mulige risiko for hypersensitivitetsreaktioner, herunder SCAR, er knyttet til alle produkter indeholdende ambroxol eller bromhexin.
Hypersensitivity reactions are dose and formulation independent, therefore the possible risk of developing hypersensitivity reactions including SCARs is inherent to all ambroxol- and bromhexinecontaining products.
På dette grundlag anses der for at være lige stor følsomhed i alle aldersgrupper (pædiatriske, voksne og ældre) over for formodede hypersensitivitetsrelaterede uønskede virkninger af ambroxol eller bromhexin.
Based on these data it is considered that the susceptibility of all age groups (paediatric, adults and elderly) to putative hypersensitivity-related undesirable effects of ambroxol or bromhexine is likely similar.
Vedrørende virkningen af produkter indeholdende ambroxol og bromhexin konkluderede PRAC, at der var opnået moderat positive resultater, men at evidensen for virkningen af ambroxol og bromhexin var behæftet med en række begrænsninger og mangler.
In relation to the efficacy of ambroxol- and bromhexine-containing products, the PRAC concluded that although modest positive results were reported, the evidence of efficacy of ambroxol and bromhexine suffered from a number of limitations and deficiencies.
Disse bivirkninger er imidlertid allerede er anført i produktinformationen for de fleste produkter indeholdende ambroxol og bromhexin, og analysen af de hyppigst indberettede bivirkninger, udvalgt ved søgning med den standardiserede (brede) MedDRA-søgeterm "Hypersensitivity", viste ingen nye sikkerhedsproblemer.
However, these adverse reactions are already listed in the product information of most ambroxol- and bromhexinecontaining products and the analysis of the most frequently reported adverse events selected by the SMQ Hypersensitivity (broad) did not identify any new safety concerns.
PRAC var af den opfattelsen, at den mulige risiko for SCAR kan håndteres tilstrækkeligt ved de foreslåede ændringer af produktinformationen, der informerer omsorgsgivere og patienter om risikoen og giver mulighed for tidlig påvisning af tegn på SCAR og øjeblikkelig seponering af behandlingen, hvis de indtræder.
The PRAC was of the view that the possible risk of SCARs can be adequately addressed by the proposed amendments to the PI to inform caregivers and patients of the risk and allow early identification of signs of SCARs and immediate discontinuation of treatment should they occur.
Vedrørende forsinkede hypersensitivitetsreaktioner forbundet med SCAR er enkelte tilfælde blevet vurderet til at have sikker sammenhæng med ambroxol.
With regards to delayed hypersensitivity reactions associated with SCARs, a few cases have been assessed as certainly related to ambroxol.
• PRAC fandt, at ambroxol og bromhexin er forbundet med øget risiko for hypersensitivitetsreaktioner
• The PRAC considered that ambroxol and bromhexine are associated with an increased risk of hypersensitivity reactions.
Ved vurderingen af de individuelle case-rapporter fandt PRAC, at det i betragtning af arten af disse hændelser er rimelig sandsynligt, at alle produkter indeholdende ambroxol og bromhexin er forbundet med øget risiko for SCAR, herunder kombinationsprodukter.
Based on the evaluation of the individual case reports, considering the nature of these events the PRAC was of the view that there is a reasonable possibility that all ambroxol and bromhexine-containing products are associated with an increased risk of SCARs including combination products.
Analyse af sikkerhedsoplysningerne fra indehaveren af markedsføringstilladelsen, fra EudraVigilance og fra litteraturen viser, at formuleringer af ambroxol og bromhexin til forskellige indikationer er blevet sat i forbindelse med indberettede svære hypersensitivitetsreaktioner af straks-typen.
Analysis of the safety information submitted by the MAH, from Eudravigilance and from the literature, demonstrates that ambroxol and bromhexine formulations in their different indications have been associated with reports of serious immediate hypersensitivity reactions.
I betragtning af alt det ovennævnte konkluderede PRAC, at de gennemgåede data støttede ændring af produktinformationen vedrørende risikoen for svære kutane bivirkninger, og at de foreliggende data ikke begrunder yderligere aldersbegrænsninger, der afspejler betænkelighederne ved benefit/riskforholdet for produkter indeholdende ambroxol og bromhexin.
Taking all of the above into consideration, the PRAC concluded that the data reviewed supported amendments of the product information to reflect the risk of severe cutaneous adverse reactions, and that further age restrictions to reflect the concerns about the benefit-risk balance of ambroxol- and bromhexine-containing products are not justified on the basis of the data available.
De godkendte indikationer for bromhexin i henhold til det centrale datablad for originalproduktet er sekretolytisk behandling, ændret slimproduktion eller -udskillelse (akut og kronisk sinuitis) og Sjögrens syndrom.
The authorised indications of bromhexine, as listed in the Company Core Data Sheet of the originator, are secretolytic therapy, alteration in the production or elimination of mucus (acute and chronic sinusitis) and Sjögren's syndrome.
Ambroxol og bromhexin markedsføres i en række formuleringer til oral, nasal, oromucosal, intravenøs og rektal administration under forskellige handelsnavne.
These products are contra-indicated in different subsets of the paediatric population in the EU MS. Ambroxol and bromhexine are marketed in several formulations for oral, nasal, oromucosal, intravenous or rectal administration under various invented names.
De godkendte indikationer for ambroxol i henhold til virksomhedens centrale datablad for originalproduktet er sekretolytisk behandling, forebyggelse og behandling af akut lungesvigtsyndrom hos børn (Infant Respiratory Distress Syndrome, IRDS), forebyggelse og behandling af postoperative bronkopulmonale komplikationer (PPC) samt smertelindring ved akut ondt i halsen.
The authorised indications of ambroxol, as listed in the Company Core Data Sheet of the originator, are secretolytic therapy, prophylaxis and treatment of Infant Respiratory Distress Syndrome (IRDS), prophylaxis and treatment of post-operative bronchopulmonary complications (PPC) and pain relief in acute sore throat.
Ambroxolformuleringer indiceret til sekretolytisk behandling og forebyggelse eller behandling af akut lungesvigtsyndrom hos børn (IRDS) og postoperative bronkopulmonale komplikationer (PPC) er desuden blevet sat i forbindelse med forsinkede hypersensitivitetsreaktioner uden svære hudskader.
In addition, ambroxol formulations indicated in secretolytic therapy and prophylaxis or treatment of IRDS and PPC have been associated with delayed-onset hypersensitivity reactions without severe skin injury.
Ved gennemgang af data til støtte for sikkerhedsproblemerne var PRAC af den opfattelse, at produkter indeholdende ambroxol og bromhexin er forbundet med case-rapporter om hypersensitivitet af strakstypen og forsinket hypersensitivitet, herunder hypersensitivitetsreaktioner, anafylaktiske reaktioner inkl.
When considering data in support of the safety issues, the PRAC was of the view that ambroxol- and bromhexine-containing products are associated with case reports of immediate and delayed hypersensitivity including hypersensitivity reactions, anaphylactic reactions including anaphylactic shock, angioedema, pruritus, rash and urticaria.
PRAC fandt det rimelig sandsynligt, at ambroxol og bromhexin har sammenhæng med alvorlige hypersensitivitetsreaktioner af forsinket type med ledsagende SCAR.
The PRAC considered that there was a reasonable possibility that ambroxol and bromhexine are associated with serious delayed-type hypersensitivity reactions associated with SCARs.
Da SCAR undertiden sætter ind med influenzalignende symptomer, kan nogle patienter desuden tænkes at begynde at tage ambroxol eller bromhexin for at dæmpe disse symptomer.
As SCARs sometimes start with flu-like symptoms some patients might also start taking ambroxol or bromhexine to alleviate these symptoms whereas the typical skin reactions appear later and ambroxol or bromhexine might be considered as suspect drug.
• PRAC fandt det rimelig sandsynligt, at der er en risiko for SCAR knyttet til ambroxol og bromhexin
• The PRAC considered that there is a reasonable possibility of a risk of SCARs associated with ambroxol and bromhexine.
Lægemidler indeholdende ambroxol og bromhexin fås som håndkøbsmedicin og som receptpligtig medicin.
Ambroxol- and bromhexine-containing medicines are available as over-the-counter (OTC) as well as prescription-only medicines (POM).
Derudover tog PRAC hensyn til alle undersøgelser, der senere er indsendt af markedsføringstilladelsesindehaverne.
In addition, all studies conducted more recently submitted by the MAHs were also considered by the PRAC.
PRAC fandt, at der kun var svag evidens for en risiko for SCAR i forbindelse med ambroxol og bromhexin.
The PRAC considered that the evidence of risk of SCARs associated with ambroxol and bromhexine is weak.