Contiroxin 40 Mg Prolonged-Release Tablets
Out of date information, search anotherSUMMARY OF PRODUCT CHARACTERISTICS
1 NAME OF THE MEDICINAL PRODUCT
Contiroxin 40 mg Prolonged-release Tablets
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
Each prolonged-release tablet contains 40 mg oxycodone hydrochloride corresponding to 35.9 mg oxycodone.
Excipients with known effects:
Each prolonged-release tablet contains a maximum of 12 mg sucrose.
For the full list of excipients, see section 6.1.
3 PHARMACEUTICAL FORM
Prolonged-release tablet
Orange, biconvex, oblong prolonged-release tablets with a breakline on both sides.
The prolonged-release tablets can be divided into equal doses.
4 CLINICAL PARTICULARS
4.1 Therapeutic indications
Severe pain, which can be adequately managed only with opioid analgesics
4.2 Posology and method of administration
The dosage depends on the intensity of pain and the patient’s individual susceptibility to the treatment. The following general dosage recommendations apply:
Adults
Dose titration and adjustment
In general, the initial dose for opioid naive patients is 10 mg oxycodone hydrochloride given at intervals of 12 hours. Some patients may benefit from a starting dose of 5 mg to minimize the incidence of side effects.
Patients already receiving opioids may start treatment with higher dosages taking into account their experience with former opioid therapies.
For dose adjustment 20 mg, 40mg and 80 mg Oxycodone Hydrochloride Prolonged-release Tablets are available. For doses not realisable/practicable with this strength other strengths may be used.
According to well-controlled clinical studies 10-13 mg oxycodone hydrochloride correspond to approximately 20 mg morphine sulphate, both in the prolonged-release formulation.
Because of individual differences in sensitivity for different opioids, it is recommended that patients should start conservatively with Oxycodone Hydrochloride Prolonged-release Tablets after conversion from other opioids, with 50-75% of the calculated oxycodone dose.
Some patients who take Oxycodone Hydrochloride Prolonged-release Tablets following a fixed schedule need rapid release analgesics as rescue medication in order to control breakthrough pain. Oxycodone Hydrochloride Prolonged-release Tablets are not indicated for the treatment of acute pain and/or breakthrough pain. The single dose of the rescue medication should amount to 1/6 of the equianalgesic daily dose of Oxycodone Hydrochloride Prolonged-release Tablets. Use of the rescue medication more than twice daily indicates that the dose of Oxycodone Hydrochloride Prolonged-release Tablets needs to be increased. The dose should not be adjusted more often than once every 1-2 days until a stable twice daily administration has been achieved.
Following a dose increase from 10 mg to 20 mg taken every 12 hours dose adjustments should be made in steps of approximately one third of the daily dose. The aim is a patient-specific dosage which, with twice daily administration, allows for adequate analgesia with tolerable undesirable effects and as little rescue medication as possible as long as pain therapy is needed.
Even distribution (the same dose mornings and evenings) following a fixed schedule (every 12 hours) is appropriate for the majority of the patients. For some patients it may be advantageous to distribute the doses unevenly. In general, the lowest effective analgesic dose should be chosen. For the treatment of non malignant pain a daily dose of 40 mg is generally sufficient; but higher dosages may be necessary. Patients with cancer-related pain may require dosages of 80 to 120 mg, which in individual cases can be increased to up to 400 mg. If even higher doses are required, the dose should be decided individually balancing efficacy with the tolerance and risk of undesirable effects.
Method of administration
For oral use.
Oxycodone Hydrochloride Prolonged-release Tablets should be taken twice daily based on a fixed schedule at the dosage determined.
The tablets may be taken with or independent of meals with a sufficient amount of liquid. Oxycodone Hydrochloride Prolonged-release Tablets must be swallowed, not chewed.
Discontinuation of treatment
When a patient no longer requires therapy with oxycodone, it may be advisable to taper the dose gradually to prevent symptoms of withdrawal.
Duration of administration
Oxycodone Hydrochloride Prolonged-release Tablets should not be taken longer than necessary. If long-term treatment is necessary due to the type and severity of the illness careful and regular monitoring is required to determine whether and to what extent treatment should be continued. If opioid therapy is no longer indicated it may be advisable to reduce the daily dose gradually in order to prevent symptoms of a withdrawal syndrome.
Children under 18 years of age
Oxycodone Hydrochloride Prolonged-release Tablets are not recommended for children under 18 years of age.
Older people
The lowest dose should be administered with careful titration to pain control.
Patients with renal or hepatic impairment
The dose initiation should follow a conservative approach in these patients. The recommended adult starting dose should be reduced by 50% (for example a total daily dose of 10 mg orally in opioid naive patients), and each patient should be titrated to adequate pain control according to their clinical situation.
Other risk patients
Risk patients, for example patients with low body weight or slow metabolism of medicinal products, should initially receive half the recommended adult dose if they are opioid naive.
Therefore the lowest recommended dosage in the SPC, i.e. 10 mg, may not be suitable as a starting dose.
Dose titration should be performed in accordance with the individual clinical situation.
Oxycodone Hydrochloride Prolonged-release Tablets should not be taken with alcoholic beverages.
4.3 Contraindications
• Hypersensitivity to oxycodone hydrochloride or to any of the excipients listed in section 6.1.
• Severe respiratory depression with hypoxia and/or hypercapnia.
• Severe chronic obstructive pulmonary disease.
• Cor pulmonale.
• Severe bronchial asthma.
• Paralytic ileus.
• Acute abdomen, delayed gastric emptying
4.4 Special warnings and precautions for use
Oxycodone Hydrochloride Prolonged-release Tablets have not been studied in children younger than 18 years of age. The safety and efficacy of the tablets have not been demonstrated and the use in children younger than 18 years of age is therefore not recommended.
Caution is required in elderly or debilitated patients, in patients with severe impairment of lung, liver or kidney function, myxoedema, hypothyroidism,
Addison’s disease, adrenocortical insufficiency, intoxication psychosis (e.g. alcohol), prostatic hypertrophy, alcoholism, known opioid dependence, delirium tremens, pancreatitis, diseases of the biliary tract, biliary or ureteric colic, inflammatory bowel disorders, conditions with increased brain pressure, disturbances of circulatory regulation (e.g. hypotension, hypovolaemia), epilepsy or seizure tendency and in patients taking MAO inhibitors.
As with all opioid preparations, oxycodone products should be used with caution following abdominal surgery as opioids are known to impair intestinal motility and should not be used until the physician is assured of normal bowel function.
Patients with severe hepatic impairment should be closely monitored.
Respiratory depression is the most significant risk induced by opioids and is most likely to occur in elderly or debilitated patients. The respiratory depressant effect of oxycodone can lead to increased carbon dioxide concentrations in blood and hence in cerebrospinal fluid. In predisposed patients opioids can cause severe decrease in blood pressure.
Long-term use of Oxycodone Hydrochloride Prolonged-release Tablets can cause the development of tolerance which leads to the use of higher doses in order to achieve the desired analgesic effect. There is a cross-tolerance to other opioids. Chronic use of Oxycodone Hydrochloride Prolonged-release Tablets can cause physical dependence. Withdrawal symptoms may occur following abrupt discontinuation of therapy. If therapy with oxycodone is no longer required it may be advisable to reduce the daily dose gradually in order to avoid the occurrence of a withdrawal syndrome. Withdrawal symptoms may include yawning, mydriasis, lacrimation, rhinorrhoea, tremor, hyperhidrosis, anxiety, agitation, convulsions and insomnia.
Hyperalgesia that will not respond to a further dose increase of oxycodone may very rarely occur, particularly in high doses. An oxycodone dose reduction or change to an alternative opioid may be required.
Oxycodone Hydrochloride Prolonged-release Tablets have a primary dependence potential. However, when used as directed in patients with chronic pain the risk of developing physical or psychological dependence is markedly reduced or needs to be assessed in a differentiated manner. There are no data available on the actual incidence of psychological dependence in chronic pain patients. In patients with a history of alcohol and drug abuse the medicinal product must be prescribed with special care.
Oxycodone Hydrochloride prolonged-release tablets are not recommended for preoperative use or within the first 12-24 hours post-operatively.
This medicinal product contains sucrose. Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase isomaltase insufficiency should not take this medicine.
In case of abusive parenteral venous injection the tablet excipients (especially talc) may lead to necrosis of the local tissue, granulomas of the lung or other serious, potentially fatal events. To avoid damage to the controlled release properties of the tablets the prolonged release tablets must not be chewed or crushed. The administration of chewed or crushed tablets leads to rapid release and absorption of a potentially fatal dose of oxycodone (see section 4.9).
Concomitant use of alcohol and Oxycodone Hydrochloride prolonged release tablets may increase the undesirable effects of Oxycodone Hydrochloride prolonged release tablets; concomitant use should be avoided.
4.5 Interaction with other medicinal products and other forms of interaction
Central nervous system depressants (e.g. sedatives, hypnotics, phenothiazines, neuroleptics, anaesthetics, antidepressants, muscle relaxants, antihistamines, antiemetics) and other opioids or alcohol can enhance the adverse reactions of oxycodone, in particular respiratory depression.
Anticholinergics (e.g. neuroleptics, antihistamines, antiemetics, antiparkinson drugs) can enhance the anticholinergic undesirable effects of oxycodone (such as constipation, dry mouth or micturition disorders).
MAO inhibitors are known to interact with narcotic analgesics, producing CNS excitation or depression with hyper- or hypotensive crisis (see section 4.4). Oxycodone should be used with caution in patients administered MAO-inhibitors or who have received MAO-inhibitors during the last two weeks (see section 4.4).
Oxycodone is metabolised mainly by CYP3A4, with a contribution from CYP2D6. The activities of these metabolic pathways may be inhibited or induced by various coadministered drugs or dietary elements.
CYP3A4 inhibitors, such as macrolide antibiotics (e.g. clarithromycin, erythromycin and telithromycin), azol-antifungals (e.g. ketoconazole, voriconazole, itraconazole, and posaconazole), protease inhibitors (e.g. boceprevir, ritonavir, indinavir, nelfinavir and saquinavir), cimetidine and grapefruit juice may cause a reduced clearance of oxycodone that could cause an increase of the plasma concentrations of oxycodone. Therefore the oxycodone dose may need to be adjusted accordingly.
Some specific examples are provided below:
• Itraconazole, a potent CYP3A4 inhibitor, administered 200 mg orally for five days, increased the AUC of oral oxycodone. On average, the AUC was approximately 2.4 times higher (range 1.5 - 3.4).
• Voriconazole, a CYP3A4 inhibitor, administered 200 mg twice-daily for four days (400 mg given as first two doses), increased the AUC of oral oxycodone. On average, the AUC was approximately 3.6 times higher (range 2.7 - 5.6).
• Telithromycin, a CYP3A4 inhibitor, administered 800 mg orally for four days, increased the AUC of oral oxycodone. On average, the AUC was approximately 1.8 times higher (range 1.3 - 2.3).
• Grapefruit Juice, a CYP3A4 inhibitor, administered as 200 ml three times a day for five days, increased the AUC of oral oxycodone. On average, the AUC was approximately 1.7 times higher (range 1.1 - 2.1).
CYP3A4 inducers, such as rifampicin, carbamazepin, phenytoin and St Johns Wort may induce the metabolism of oxycodone and cause an increased clearance of oxycodone that could cause a reduction of the plasma concentrations of oxycodone. The oxycodone dose may need to be adjusted accordingly.
Some specific examples are provided below:
• St Johns Wort, a CYP3A4 inducer, administered as 300 mg three times a day for fifteen days, reduced the AUC of oral oxycodone. On average, the AUC was approximately 50% lower (range 37-57%).
• Rifampicin, a CYP3A4 inducer, administered as 600 mg once-daily for seven days, reduced the AUC of oral oxycodone. On average, the AUC was approximately 86% lower
Drugs that inhibit CYP2D6 activity, such as paroxetine and quinidine, may cause decreased clearance of oxycodone which could lead to an increase in oxycodone plasma concentrations.
Clinically relevant changes in International Normalized Ratio (INR) in both directions have been observed in individuals if coumarin anticoagulants are coapplied with Oxycodone Hydrochloride prolonged release tablets.
Alcohol may enhance the pharmacodynamic effects of Oxycodone Hydrochloride prolonged release tablets; concomitant use should be avoided.
4.6 Pregnancy and lactation
Use of this medicinal product should be avoided to the extent possible in patients who are pregnant or lactating.
Pregnancy
There are limited data from the use of oxycodone in pregnant women. Infants born to mothers who have received opioids during the last 3 to 4 weeks before giving birth should be monitored for respiratory depression. Withdrawal symptoms may be observed in the newborn of mothers undergoing treatment with oxycodone.
Breastfeeding
Oxycodone may be secreted in breast milk and may cause respiratory depression in the newborn. Oxycodone should, therefore, not be used in breastfeeding mothers.
4.7 Effects on ability to drive and use machines
Oxycodone can impair alertness and reactivity to such an extent that the ability to drive and operate machinery is affected or ceases altogether.
With stable therapy, a general ban on driving a vehicle is not necessary. The treating physician must assess the individual situation.
This medicine can impair cognitive function and can affect a patient’s ability to drive safely. This class of medicine is in the list of drugs included in regulations under 5a of the Road Traffic Act 1988. When prescribing this medicine, patients should be told:
• The medicine is likely to affect your ability to drive
• Do not drive until you know how the medicine affects you
• It is an offence to drive while under the influence of this medicine
• However, you would not be committing an offence (called ‘statutory defence’) if:
o The medicine has been prescribed to treat a medical or dental problem and
o You have taken it according to the instructions given by the prescriber and in the information provided with the medicine and o It was not affecting your ability to drive safely.
4.8 Undesirable effects
Oxycodone can cause respiratory depression, miosis, bronchial spasms and spasms of the smooth muscles and can suppress the cough reflex.
The adverse events considered at least possibly related to treatment are listed below by system organ class and absolute frequency. Frequencies are defined as:
Very common (>1/10)
Common (>1/100 to <1/10)
Uncommon (>1/1,000 to <1/100)
Rare (>1/10,000 to <1/1,000)
Very rare (<1/10,000), not known (cannot be estimated from the available data)
Blood and lymphatic system disorders:
Rare: Lymphadenopathy.
Endocrine disorders:
Uncommon: syndrome of inappropriate antidiuretic hormone secretion.
Immune system disorders:
Uncommon: Hypersensitivity.
Not known: Anaphylactic responses.
Metabolism and nutrition disorders: Common: Decreased appetite
Uncommon: Dehydration
Psychiatric disorders:
Common: Anxiety, confusional state, depression, nervousness, insomnia,
|
Uncommon: |
abnormal thinking. Agitation, affect lability, euphoric mood, hallucinations, decreased libido, drug dependence (see section 4.4), hyperacousis |
|
Not known: |
Aggression |
Nervous system disorders:
Very common: Somnolence, dizziness, headache
|
Common: |
Tremor |
|
Uncommon: |
Amnesia, convulsion, hypertonia, both increased and decreased muscle tone, involuntary muscle contractions, hypaesthesia, coordination disturbances, speech disorder, syncope, paraesthesia, dysgeusia. |
|
Rare: |
Muscle spasm |
|
Not known: |
Hyperalgesia |
|
Eye disorders: Uncommon: |
Visual impairment, miosis. |
Ear and labyrinth disorders:
Uncommon: Vertigo
Cardiac disorders:
Uncommon: Palpitations (in the context of withdrawal syndrome),
supraventricular tachycardia.
Vascular disorders:
Uncommon: Vasodilatation
Rare: Hypotension, orthostatic hypotension.
Respiratory, thoracic and mediastinal disorders:
Common: Dyspnoea, bronchospasm
Uncommon: Respiratory depression, increased coughing, pharyngitis, rhinitis,
voice changes.
Gastrointestinal disorders:
Very common: Constipation, nausea, vomiting.
Common: Dry mouth, abdominal pain, diarrhoea, dyspepsia.
Uncommon: Dysphagia, oral ulcers, gingivitis, stomatitis, flatulence, eructation,
ileus.
Rare: Gum bleeding, increased appetite, tarry stool, tooth staining and
damage.
Not known: Dental caries
Hepato-biliary disorders
Uncommon: Increased hepatic enzymes.
Not known: Cholestasis, biliary colic.
Skin and subcutaneous tissue disorders:
Very common: Pruritus
Common: Skin eruptions including rash, in rare cases increased
photosensitivity, in isolated cases exfoliative dermatitis, hyperhidrosis.
Uncommon: Dry skin, herpes simplex.
Rare: Urticaria
Renal and urinary disorders:
Common: Increased urge to urinate
Uncommon: Urinary retention
Rare: Haematuria.
Reproductive system and breast disorders: Uncommon: Erectile dysfunction
Not known: Amenorrhoea.
General disorders and administration site conditions:
Common: Asthenic conditions
Uncommon: Chills, accidental injuries, pain (e.g. chest pain), oedema, peripheral
oedema, migraine, drug withdrawal syndrome, malaise, drug tolerance, thirst.
Rare:
Weight changes (increase or decrease); cellulitis.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.
4.9 Overdose
Symptoms and intoxication:
Miosis, respiratory depression, somnolence, reduced skeletal muscle tone and drop in blood pressure. In severe cases circulatory collapse, stupor, coma, bradycardia and non-cardiogenic lung oedema may occur; abuse of high doses of strong opioids such as oxycodone can be fatal.
Therapy of intoxications:
Primary attention should be given to the establishment of a patent airway and institution of assisted or controlled ventilation
In the event of overdosing intravenous administration of an opiate antagonist (e.g. 0.4-2 mg intravenous naloxone) may be indicated. Administration of single doses must be repeated depending on the clinical situation at intervals of 2 to 3 minutes. Intravenous infusion of 2 mg of naloxone in 500 ml isotonic saline or 5% dextrose solution (corresponding to 0.004 mg naloxone/ml) is possible. The rate of infusion should be adjusted to the previous bolus injections and the response of the patient.
Gastric lavage can be taken into consideration. Consider activated charcoal (50 g for adults, 10 -15 g for children), if a substantial amount has been ingested within 1 hour, provided the airway can be protected. It may be reasonable to assume that late administration of activated charcoal may be beneficial for prolonged release preparations; however there is no evidence to support this.
For speeding up the passage a suitable laxative (e.g. a PEG based solution) may be useful.
Supportive measures (artificial respiration, oxygen supply, administration of vasopressors and infusion therapy) should, if necessary, be applied in the treatment of accompanying circulatory shock. Upon cardiac arrest or cardiac arrhythmias cardiac massage or defibrillation may be indicated. If necessary, assisted ventilation as well as maintenance of water and electrolyte balance.
5 PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Natural opium alkaloids ATC-Code: N02A A05
Oxycodone shows an affinity to kappa, mu and delta opioid receptors in the brain and spinal cord. It acts at these receptors as an opioid agonist without an antagonistic effect. The therapeutic effect is mainly analgesic and sedative. Compared to rapid-release oxycodone, given alone or in combination with other substances, the prolonged-release tablets provide pain relief for a markedly longer period without increased occurrence of undesirable effects.
5.2 Pharmacokinetic properties
Absorption:
The relative bioavailability of Oxycodone Hydrochloride Prolonged-release Tablets is comparable to that of rapid release oxycodone with maximum plasma concentrations being achieved after approximately 4.5-7 hours after intake of the prolonged-release tablets compared to 1 to 1.5 hours. Peak plasma concentrations and oscillations of the concentrations of oxycodone from the prolonged-release and rapid-release formulations are comparable when given at the same daily dose at intervals of 12 and 6 hours respectively.
A fat-rich meal before the intake of the tablets does not affect the maximum concentration or the extent of absorption of oxycodone.
The tablets must not be crushed or chewed as this leads to rapid oxycodone release due to the damage of the prolonged release properties.
Distribution:
The absolute bioavailability of oxycodone is approximately two thirds relative to parenteral administration. In steady state, the volume of distribution of oxycodone amounts to 2.6 l/kg; plasma protein binding to 38-45%; the elimination half-life to 4 to 6 hours and plasma clearance to 0.8 l/min. The elimination half-life of oxycodone from prolonged-release tablets is 4-5 hours with steady state values being achieved after a mean of 1 day.
Biotransformation:
Oxycodone is metabolised in the intestine and liver via the P450 cytochrome system to noroxycodone and oxymorphone as well as to several glucuronide conjugates. In vitro studies suggest that therapeutic doses of cimetidine probably have no relevant effect on the formation of noroxycodone. In man, quinidine reduces the production of oxymorphone while the pharmacodynamic properties of oxycodone remain largely unaffected. The contribution of the metabolites to the overall pharmacodynamic effect is irrelevant.
Elimination:
Oxycodone and its metabolites are excreted via urine and faeces. Oxycodone crosses the placenta and is found in breast milk.
Linearity/non-linearity:
The 20, 40 and 80 mg prolonged-release tablets are bioequivalent in a dose proportional manner with regard to the amount of active substance absorbed as well as comparable with regard to the rate of absorption.
5.3 Preclinical safety data
There is insufficient data on the reproduction toxicity properties of oxycodone and there is no data available on fertility and postnatal effects following intrauterine exposure. Oxycodone did not cause malformations in rats and rabbits at dosages, which were 1.5 to 2.5 times of the human dose of 160 mg/day, based on mg/kg basis.
Long-term studies on carcinogenicity have not been performed.
6 PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Tablet core:
Sugar spheres (sucrose, maize starch)
Hypromellose Macrogol 6000 Talc
Ethyl cellulose Hydroxypropylcellulose Propylene glycol Magnesium stearate Microcrystalline cellulose Colloidal anhydrous silica
Tablet coating:
Hypromellose
Talc
Macrogol 6000 Titanium dioxide (E 171)
Iron oxide yellow (E 172)
Iron oxide red (E 172)
6.2 Incompatibilities
Not applicable.
6.3 Shelf life
4 years.
6.4 Special precautions for storage
This medicinal product does not require any special storage conditions.
6.5 Nature and contents of container
Alu/PVC/PVDC blister with Child-resistant closure.
Pack sizes:
10, 20, 28, 30, 40, 50, 56, 60, 100 and 112 prolonged-release tablets
HDPE bottles with PP twist-off caps Pack sizes:
50, 100 and 250 prolonged-release tablets.
Not all pack sizes may be marketed.
6.6 Special precautions for disposal
No special requirements.
7 MARKETING AUTHORISATION HOLDER
Sandoz Limited Frimley Business Park,
Frimley,
Camberley,
Surrey,
GU16 7SR.
United Kingdom
8 MARKETING AUTHORISATION NUMBER(S)
PL 04416/0754
9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
20/08/2012
10 DATE OF REVISION OF THE TEXT
25/09/2014