natgillin/translations-raw huggingface dataset:
Derudover anmodede CHMP om, at der udføres en undersøgelse af lægemiddelanvendelse for at opnå en bedre karakterisering af den typiske kliniske ordinationspraksis for disse lægemidler hos repræsentative grupper af læger og vurdere de vigtigste grunde til, at de ordineres. 
Furthermore the CHMP requested a drug utilisation study (DUS) to be conducted in order to better characterise prescribing practices for these medicinal products during typical clinical use in representative groups of prescribers and to assess main reasons for prescription.
Der fandtes ingen tilfælde af kræft, medfødte misdannelser, spontanabort eller nedsat mandlig fertilitet ved gennemgang af kliniske undersøgelser og litteraturen. 
No cases of cancer, congenital abnormalities, spontaneous abortion and impaired male fertility were retrieved from a review of clinical trials and literature.
Disse foranstaltninger skal ligeledes indgå i risikostyringsplanen, 
These measures are to be included in the RMP.
Det konkluderedes, at M1 (SL18.0740) er uden potentiale som mutagen (genmutationer) eller som clastogen (strukturel kromosombeskadigelse), men kan inducere aneuploidi (numeriske kromosomafvigelser). 
It was concluded that M1 (SL18.0740) is devoid of mutagenic (gene mutations) and clastogenic (structural chromosome damage) potential, but is able to induce aneuploidy (numerical chromosome damage).
Der blev vedtaget en ændring af produktinformationen vedrørende dette punkt. 
An amendment to the product information was agreed to address this concern.
Da der er ikke tidligere var udført relevante genotoksikologiske undersøgelser med aglyconmetabolitten SL59.0955, blev der udført supplerende undersøgelser (kromosomskade-assay) til karakterisering af den toksiske profil af denne metabolit og dens evne til at inducere aneuploidi i ikkekliniske undersøgelser in vitro (op til 600 µg/ml) og in vivo (op til 150 mg/kg): 
Since no relevant genetic toxicology studies were previously performed with the aglycone metabolite SL59.0955, complementary studies (chromosome damage assays) were performed in order to investigate the genotoxic profile of this metabolite and its ability to induce aneuploidy in nonclinical in vitro (up to 600 µg/mL) and in vivo (up to 150 mg/kg):
Derudover fandt CHMP, at den nye anbefaling om antal behandlingsdage skulle ledsages af en tilsvarende begrænsning af pakningsstørrelsen (til 30 tabletter eller kapsler for 4 mg pakningen, til 14 tabletter eller kapsler for 8 mg pakningen, og til ti hætteglas/ampuller). 
In addition, the CHMP was of the view that the package size should be restricted according to the new treatment-days scheme recommended (up to 30 tablets or capsules/4 mg pack, up to 14 tablets or capsules/8 mg pack and up to 10 vials/ampoules).
Produkterne skal også være kontraindiceret til kvinder i den fertile alder, der ikke anvender sikker kontraception, samt under amning. 
These products should also be contraindicated in women of childbearing potential not using contraception and during lactation.
Der skal foretages løbende overvågning af alle sikkerhedssignaler, der er korreleret med aneuploidi (dvs. teratogenicitet, embryoføtal toksicitet/spontanabort, nedsat mandlig fertilitet og kræft) og indberetning om graviditeter med henblik på at indsamle strukturerede data om accidentel eksponering for lægemidlet. 
Continuous monitoring of any safety signal correlated with aneuploidy (i.e. teratogenicity, embryo-foetal toxicity / spontaneous abortion, impaired male fertility and cancer) and pregnancy reporting to collect structured data on accidental exposure to the drug should be performed.
Til imødegåelse af risiciene for teratogenicitet og embryotoksicitet/spontanabort vedtog CHMP en kontraindikation for TCC i hele graviditeten og ammeperioden samt hos kvinder i den fødedygtige alder, der ikke anvender antikonception. 
To address the risks of teratogenicity and embryo-toxicity/spontaneous abortions the CHMP agreed on contraindicating TCC during the entire pregnancy period, during lactation, and in women of childbearing potential not using contraception.
• seks tilfælde af medfødte misdannelser (et af multiple misdannelser medførende abort, et af pulmonal hypoplasi, et af ganespalte, et af spina bifida, et af Polands syndrom, og et af persisterende ductus arteriosus), 
• six cases of congenital abnormalities (i.e. one multiple malformations leading to abortion, one pulmonary hypoplasia, one cleft palate, one spina bifida, one Poland's syndrome, one patent ductus arteriosus),
Genotoksicitetsdata for aglycon-metabolitten SL59.0955 (M2) 
Genotoxicity data on aglycone metabolite SL59.0955 (M2)
• og 2 tilfælde med ukendt eksponeringsperiode: o 1 tilfælde af teratogene virkninger (misdannelser) ved eksponering tidligt i graviditeten, o 1 tilfælde, hvor udviklingen af graviditeten var usikker som følge af manglende dokumentation. 
• and 2 cases with unknown exposure period: o 1 case of teratogenic effects (malformations) associated with exposure in early pregnancy, o 1 case with an unknown evolution of the pregnancy due to lack of documentation.
CHMP gennemgik alle foreliggende data fra prækliniske og kliniske undersøgelser, den publicerede litteratur og erfaringer efter markedsføring vedrørende aneuploidi for lægemidler indeholdende TCC til systemisk brug. 
The CHMP reviewed all available data from pre-clinical and clinical studies, literature and post-marketing experience on aneuploidy for TCC containing medicinal products for systemic use.
Dette skete ved et AUC af M1 i plasma på 4 073 ngh/ml, som er over 20 gange mere end den observerede eksponering for M1 af mennesker efter en oral dosis af TCC på 8 mg to gange dagligt (175 ngh/ml ved 30 min). 
This was associated with M1 plasma AUC of 4073 ng.h/mL, which is more than 20 times higher than M1 exposure observed in human after a 8 mg bid oral dose of TCC (175 ng.h/mL at 30 min).
• udvalget gennemgik alle foreliggende data fra prækliniske og kliniske undersøgelser, farmakoepidemiologiske undersøgelser, den publicerede litteratur og erfaringer efter markedsføring om sikkerheden af systemiske lægemidler indeholdende thiocolchicosid hvad angår dets genotoksicitet, 
• The Committee considered all available data from pre-clinical, clinical studies, pharmacoepidemiological studies, published literature, post-marketing experience on the safety of thiocolchicoside containing medicinal products for systemic use with regards to its genotoxicity.
• 1 tilfælde forårsaget af eksponering i den føtale periode (dvs. et tilfælde, hvor føtotoksiske virkninger medførte påvirkning af den føtale eller neonatale vækst eller den histologiske eller funktionelle modning af dannede organer (perioden med størst risiko begynder i anden fjerdedel af graviditeten), 
• 1 case due to exposure during the foetal period (i.e. a case of foetotoxic effects that resulted in foetal or neonatal type of achieving growth impact, or histological or functional maturation of organs in place (the period during which the greatest risk begins in the second quarter of pregnancy),
Risikostyringsplanen skal indeholde en model af den nævnte formular til indberetning om graviditeter, og sammen med PSUR skal der forelægges en rapport om disse indsamlede data. 
A mock-up of the above-mentioned pregnancy reporting form should be provided in the RMP and a report on these collected data should be submitted within PSURs.
• 20 tilfælde som følge af eksponering i den embryonale periode, heraf: o to tilfælde af teratogene virkninger (misdannelser) ved eksponering tidligt i graviditeten (den første fjerdedel er perioden med størst risiko), o fire tilfælde resulterende i afbrydelse af graviditeten (3 spontanaborter og en abort fremkaldt af ikke-medicinske grunde), o fem tilfælde med gunstig udvikling (ingen virkning på den nyfødte), o ni tilfælde, hvor udviklingen af graviditeten var usikker som følge af manglende dokumentation. 
• 20 cases due to exposure during the embryonic period, of which: o two cases of teratogenic effects (malformations) associated with exposure in early pregnancy (the first quarter is the period during which the risk is the greatest), o four cases resulting in discontinuation of the pregnancy (3 spontaneous abortions and one voluntary abortion not due to medical reason), o five cases with a favourable evolution (no effect on the new born), o nine cases with an unknown evolution of the pregnancy due to lack of documentation.
Den aneugene virkning blev iagttaget ved en LOEL svarende til kun 1,6 x den humane Cmax og 4,1 x AUC (8 mg oralt to gange dagligt). 
The aneugenic effect was observed at LOEL corresponding to only 1.6 x human Cmax and 4.1 x AUC (8mg bid, Per Os (PO)).
Kliniske undersøgelser 
Clinical studies
Aneuploidi (forandringer i antallet af kromosomer og tab af heterozygositet) er en kendt potentiel risikofaktor for kræft, når den berører somatiske celler, og for teratogenicitet, embryotoksicitet/spontanaborter samt nedsat fertilitet hos manden, når den berører kønsceller1. 
Aneuploidy (variation in the number of chromosomes and loss of heterozygosity) is recognised as a potential risk factor for cancer when impacting somatic cells, and teratogenicity, embryotoxicity/spontaneous abortions and impaired male fertility when impacting germ cells1.
Efter at den nævnte kliniske fase I-undersøgelse med TCC var blevet indstillet, blev det genotoksiske potentiale af aglycon-metabolitten SL59.0955 (M2) undersøgt nærmere. 
After discontinuation of the above-mentioned phase I clinical trial with TCC, the genotoxic potential of the aglycone metabolite SL59.0955 (M2) was further investigated.
Disse PSUR skal indeholde en opgørelse over den løbende overvågning af alle sikkerhedssignaler, der korrelerer med aneuploidi, og graviditet ved accidentel eksponering for lægemidlet, 
These PSURs should include a report compiling continuous monitoring of any safety signal correlated with aneuploidy and pregnancy on accidental exposure to the drug.
Efterfølgende mekanistisk analyse med in situ-fluorescenshybridisering (FISH) med pan-centromere DNA-sonder viste, at mikronuklei ved alle behandlingsbetingelser fortrinsvis dannedes ved en aneugen mekanisme (numerisk kromosomaberration); aneuploidi blev klart bekræftet ved centromerfarvning. 
Subsequent mechanistic analysis via the use of fluorescence in situ hybridization (FISH) with pan centromeric DNA probes demonstrated that micronuclei were predominantly generated via an aneugenic (numerical chromosome abnormality) mechanism under all treatment conditions; aneuploidy was clearly confirmed by centromere staining.
CHMP var derfor af den opfattelse, at der burde træffes risikominimeringsforanstaltninger til imødegåelse af risiciene for teratogenicitet, embryotoksicitet/spontanaborter, nedsat fertilitet hos manden og kræft. 
The CHMP was therefore of the view that risk minimisation measures (RMMs) should be undertaken in order to address the risks of teratogenicity, embryo-toxicity/spontaneous abortions, impaired male fertility and cancer.
Som konklusion viste ovenstående prækliniske undersøgelser, at M2 (SL59.0955) inducerede mikronuklei in vitro og in vivo via en overvejende aneugen mekanisme ved alle behandlingsbetingelser. 
In conclusion, the results of the above pre-clinical studies showed that M2 (SL59.0955) induced micronuclei in vitro and in vivo, generated via a predominantly aneugenic mechanism under all treatment conditions.
• udvalget fandt, at systemiske lægemidler indeholdende thiocolchicosid fortsat er effektive til adjuvant behandling af smertefulde kontrakturer ved akutte columnalidelser. 
• The Committee considered that thiocolchicoside containing medicinal products for systemic use remain an effective adjuvant treatment of painful muscle contractures in acute spinal pathology.
Undersøgelsens protokol skal indgå i risikostyringsplanen. 
The study protocol should be provided within the RMP.
I denne forbindelse fandt CHMP, at indikationen “Parkinsons sygdom og lægemiddelinduceret parkinsonisme, særligt neurodyslektisk syndrom” skulle udgå, da dette er en indikation til kronisk anvendelse. 
In that respect, the CHMP was of the view that the indication in “Parkinson's disease and drug-induced Parkinsonism with special consideration to neurodyslectic syndrome” should be removed as this is an indication for chronic use.
• en in vitro-mikronukleustest i en primær kultur af humane lymfocytter med aglyconmetabolitten (SL59.0955) med centromerfarvning (Whitwell J., 2012); 
• an in vitro micronucleus (MN) test in primary culture of human lymphocytes with the aglycone metabolite (SL59.0955), with centromere staining (Whitwell J., 2012);
Der blev imidlertid ikke bestemt en NOAEL for aneugene virkninger hos hunrotter (LOEL = 25 mg/kg), og der fandtes ikke klar dosisrelateret virkning, idet der hos hanner og hunner kun var lille forskel mellem de forskellige doser hvad angår eksponeringen (AUC0-24 og Cmax) for 3-demethylthiocolchicin (SL59.0955). 
But no NOAEL for aneugenic effects was identified in rat females (LOEL = 25 mg/kg) and no clear dose related effect was observed because only slight difference in exposure (AUC0-24 and Cmax) with 3demethylthiocolchicine (SL59.0955) were observed between the different doses in males and females.
In vitro-mikronukleustesten i humane lymfocytter viste, at M2 ved alle behandlingsbetingelser inducerede mikronuklei i dyrkede humane lymfocytter fra perifert blod. 
The in vitro MN test in human lymphocytes showed that M2 induced micronuclei in cultured human peripheral blood lymphocytes in all treatment conditions.
Genotoksicitetsdata om TCC og dets vigtigste cirkulerende metabolit SL18.0740 (M1) 
Genotoxicity data on TCC and its main circulating metabolite SL18.0740 (M1)
Der blev udført en række genotoksikologiske undersøgelser på TCC og dets vigtigste identificerede metabolit 3-O-glucuronideret aglycon (SL18.0740), som er den aktive metabolit. 
Various genetic toxicology studies were conducted on TCC and on its major identified metabolite 3-O-glucuronidated aglycone (SL18.0740), which is the active metabolite.
Efter at en virksomhed indstillede sin kliniske fase I-undersøgelse med TCC på grund af nye ikkekliniske fund, anmodede den italienske lægemiddelstyrelse (AIFA) en af markedsføringstilladelsesindehaverne for TCC om at foretage en nærmere undersøgelse af TCC's genotoksiske potentiale, navnlig dets metabolitter. 
After discontinuation by a Company of a phase I clinical trial with TCC because of new non-clinical findings, the Italian medicines agency (AIFA) requested one of the Marketing Authorisation Holders (MAH) of TCC to further investigate the genotoxic potential of TCC and in particular of its metabolites; the MAH was requested to perform in vivo and in vitro preclinical studies to address the potential genotoxicity of the metabolites of TCC.
Resultaterne af en af metabolitundersøgelserne (metabolit SL59.0955, M2) gav anledning til betænkelighed: Der blev fundet tegn på genotoksisk potentiale i nye data om den aneugene virkning af M2-metabolitten af TCC i de forelagte prækliniske undersøgelser. 
The results obtained from one of the metabolites' studies (metabolite SL59.0955, M2) led to concerns: new data on the aneugenic effect of the M2 metabolite of TCC generated from the submitted preclinical studies indicated a signal of genotoxic potential
I 2011 og 2012 blev der udført nye undersøgelser af genotoksiciteten af moderstoffet (TCC), dets vigtigste cirkulerende metabolit SL18.0740 og aglycon-metabolitten SL59.0955. 
New studies were performed in 2011 and 2012 regarding the genotoxicity of the parent compound (TCC), its main circulating metabolite SL18.0740 and the aglycone metabolite SL59.0955.
• en in vivo-mikronukleustest i knoglemarv fra rotter efter oral administration af aglyconmetabolitten (SL59.0955) til rotter med centromerfarvning og fuld bestemmelse af eksponeringen for SL59.0955 og 3-O-glucuronideret aglycon-metabolit (SL18.0740) med henblik på bedre bestemmelse af eksponeringstærsklen (Wase K., Oktober 2012). 
• an in vivo MN test in rat bone marrow following administration of aglycone metabolite (SL59.0955) by oral route in rats with centromere staining and with a full assessment of exposure to SL59.0955 and to 3-O-glucuronidated aglycone metabolite (SL18.0740) to better assess the threshold of exposure (Wase K., October 2012).
• Da TCC's metabolit M2 er påvist at være aneugen ved en eksponering tæt på den terapeutiske humane dosis, fandt CHMP for det første, at dosis skulle begrænses (til 8 mg peroralt gange dagligt og 4 mg intramuskulært to gange dagligt) og langtidsanvendelse undgås. 
• Firstly, since the TCC metabolite M2 has been shown to be aneugenic at exposure levels close to human therapeutic exposure, the CHMP considered that the dose should be restricted (to 8 mg bid PO and 4 mg bid by IM) and long-term use avoided.
Hvad dette angår, fandt CHMP, at indikationen “Parkinsons sygdom og lægemiddelinduceret parkinsonisme, særlig neurodyslektisk syndrom” burde udgå, da den kræver længere behandlingsvarighed. 
In that respect, the CHMP was of the view that the indication in “Parkinson's disease and druginduced Parkinsonism with special consideration to neurodyslectic syndrome” should be removed as this is a chronic condition which requires longer treatment duration.
I betragtning af risiciene fandt udvalget dog, at systemiske lægemidler indeholdende thiocolchicosid kun bør administreres til patienter over 16 år ved akutte tilstande og med en behandlingsvarighed, der ved oral indgift ikke er over 7, og ved intramuskulær indgift ikke over 5 konsekutive dage. 
However, having considered the risks, thiocolchicoside containing medicinal products for systemic use should only be administered to patients over 16 years of age in acute conditions, with treatment duration limited to 7 (oral) and 5 (IM) consecutive days.
In vivo-mikronukleustest på knoglemarv fra rotter var negativ hos handyrene efter oral administration af M2 i doser på 25, 50, 70, 100 og 150 mg/kg/d én gang dagligt i to på hinanden efterfølgende dage. 
In the in vivo MN test in rat bone marrow, after M2 oral administration once daily for two consecutive days at doses of 25, 50, 70, 100 or 150 mg/kg/d, the rats bone marrow micronucleus test was found negative in males.
Til imødegåelse heraf fandt CHMP de foreslåede risikominimeringsforanstaltninger passende (begrænsning af indikationen til akutte tilstande, begrænsning af behandlingsvarigheden til syv konsekutive dage, undgåelse af langvarig anvendelse). 
To address it, the proposed RMM (indication limited to acute conditions, treatment duration limited to seven consecutive days, avoidance of long-term use) were considered appropriate by the CHMP.
CHMP fandt derfor, at de foreliggende data bekræfter en klar aneugen virkning af thiocolchicosid-metabolitten M2 ved koncentrationer 4 gange den humane eksponering i plasma efter oral behandling med 8 mg TCC to gange dagligt (den anbefalede dosis), begyndende ved en dosis på 25 mg/kg. 
The CHMP was therefore of the view that the available data allow to confirm a clear aneugenic effect of the thiocolchicoside metabolite M2 at concentrations which are 4 fold the human exposure in plasma after oral 8 mg TCC treatment bid (recommended dose) and starting from 25 mg/kg dose.The submitted data did not allow establishing a NOEL for aneuploidy, thus not excluding the potential for a human risk.
Prækliniske undersøgelser 
Pre-clinical studies
Endelig skal oplysningsmateriale til ordinerende læger og til patienter forelægges for de nationale kompetente myndigheder som en del af risikostyringsplanen. 
Finally educational material for prescribers and for patients highlighting the risks and warnings of genotoxicity reactions will also be submitted to national competent authorities within the RMP.
På grundlag af den almindelige anvendelse ved akutte tilstande blev der indsat andre anbefalinger om dosering med begrænsning af behandlingsvarigheden til 7 dage for oral og 5 dage for intramuskulær administration; det blev ligeledes anbefalet at angive den maksimale tilladelige dosis. 
Based on common use in acute settings, other recommendations for the posology were included as the limitation of the treatment duration to 7 days in case of oral administration and to 5 days in case of IM administration; a reference to the maximum dose allowed was also recommended .Finally a 12 hours interval between 2 consecutive administrations was requested in view of the elimination half-life of the M2 metabolite.
Desuden skal alle indehavere af markedsføringstilladelse for produkterne indsende PSUR hvert 3. år. 
In addition, three-yearly PSURs should be submitted by all MAHs of these products.
Efter ovenstående bemærkninger konkluderede CHMP, at benefit/risk-forholdet fortsat er gunstigt for lægemidler indeholdende TCC til adjuverende behandling af smertefulde kontrakturer ved akutte columnalidelser hos voksne og unge over 16 år under forudsætning af de vedtagne begrænsninger, advarsler, andre ændringer i produktinformationen, supplerende lægemiddelovervågning og supplerende risikominimeringsforanstaltninger. 
Having noted the above, the CHMP concluded that the benefit-risk balance of TCC containing medicinal products indicated as adjuvant treatment of painful muscle contractures in acute spinal pathology in adults and adolescents from 16 years onwards remains favourable subject to the restrictions, warnings, other changes to the product information, additional pharmacovigilance activities and RMMs agreed.
konkluderede CHMP, at benefit/risk-forholdet fortsat er gunstigt for lægemidler indeholdende thiocolchicosid til behandling af smertefulde muskelkontrakturer ved akutte columnalidelser hos voksne og unge over 16 år under forudsætning af de vedtagne begrænsninger, advarsler, andre ændringer i produktinformationen, supplerende lægemiddelovervågning og supplerende risikominimeringsforanstaltninger. 
The Committee, as consequence, concluded that the benefit-risk balance of thiocolchicoside containing medicinal products for systemic use as adjuvant treatment of painful muscle contractures in acute spinal pathology in adults and adolescents from 16 years onwardsremains favourable, subject to the restrictions, warnings, other changes to the product information, additional pharmacovigilance activities and risk minimisation measures agreed.
CHMP finder, at der ikke kan drages definitive konklusioner om konsekvenserne af aneuploidi hos mennesker af den kliniske evidens fra de tilfælde, der er indberettet af markedsføringstilladelsesindehaverne. 
The CHMP considers that the clinical evidence within the cases reported by the MAHs concerning the consequences of aneuploidy in humans does not allow drawing definitive conclusions.
Indehaverne af markedsføringstilladelse forelagde kliniske undersøgelser og spontane indberetninger efter markedsføring. 
Clinical trials and post marketing spontaneous reports were submitted by the MAHs.
Skønt kromosomal nondisjunction er det mest hensigtsmæssige endepunkt ved undersøgelse af lavdosisvirkninger af stoffer med toksisk virkning på spindelapparatet, kunne der imidlertid ikke drages konklusioner om tærskeldoser for induktion af aneuploidi. 
Under the assay conditions, the No Observed Adverse Effect Level (NOAEL) and lowest-observedadverse-effect level (LOAEL) were also considered but while acknowledging that chromosome non disjunction (CND) is the most appropriate end-point to investigate when looking for low-dose effects of spindle poisons, conclusion on the search for threshold doses for aneuploidy induction was not possible to draw.
Eksponering over en vis tærskel vides at udløse genotoksiske mekanismer såsom aneuploidi, der påvirker celledelingen og andre mål end DNA. 
Genotoxic mechanisms, such as aneuploidy, involving cell division and non-DNA targets, are known to occur above a certain threshold of exposure.
Vedrørende risikoen for infertilitet hos manden vides forhøjet forekomst af aneuploidi af kromosomerne i sædceller at have sammenhæng med infertilitet hos manden. 
• Carcinogenicity and impaired fertility are categorised as important potential risks.Concerning the risk of male infertility: elevated sperm chromosome aneuploidy is known to be associated with male infertility.