1 NAME OF THE MEDICINAL PRODUCT

Bendroflumethiazide 2.5mg Tablets

2 QUALITATIVE AND QUANTITATIVE COMPOSITION

Each tablet contains Bendroflumethiazide 2.5mg For full list of excipients, see section 6.1

3    PHARMACEUTICAL FORM

Tablets.

White to off white circular, biconvex, uncoated tablets.

4 CLINICAL PARTICULARS

4.1    Therapeutic indications

Bendroflumethiazide is indicated for:

1.    Cases where the reduction of fluid retention by diuresis is required; oedema of cardiac, renal or hepatic origin and iatrogenic oedema

2.    Bendroflumethiazide produces a moderate but usefully prolonged fall of blood pressure in hypertensive patients. It may be used as the sole antihypertensive agent, or, as an adjunct to other drugs whose action it potentiates. In nonoedematous patients, there may be little noticeable diuretic effect.

4.2    Posology and method of administration

For oral administration

It is recommended that the tablets should be taken in the morning to avoid nocturia.

Adults and children aged 12 years and over:

Oedema

Initially, 5-10 mg in the morning, daily or on alternate days; maintenance dose 5-10 mg one to three times weekly

Hypertension

The usual dose is 2.5 mg - 5mg taken in the morning. Higher doses are rarely necessary. When Bendroflumethiazide is used concurrently with other specific hypotensive agents, the dosage of such agents should be reduced and then adjusted as necessary.

Children under 12 years of age: Dosage in children may be up to 400 mcg/kg bodyweight initially, reducing to 50-100 mcg/kg bodyweight daily for maintenance. A more appropriate dosage form may be required.

Elderly: The dosage of thiazide diuretics may need to be reduced in the elderly, Particularly when renal function is impaired, because of the possibility of electrolyte imbalance

4.3 Contraindications

Bendroflumethiazide is contra-indicated in patients with known hypersensitivity to Bendroflumethiazide, other thiazide, and excipients in the tablet.

Bendroflumethiazide is also contraindicated in patients with the following conditions:

•    Refractory hypokalaemia, hyponatraemia, or hypercalcaemia

•    Severe renal and hepatic insufficiency

•    Symptomatic hyperuricaemia

•    Addison’s disease

4.4 Special warnings and precautions for use

Bendroflumethiazide may raise serum uric acid levels with consequent exacerbation of gout insusceptible patients.

Bendroflumethiazide should be used with caution in patients with mild to moderate hepatic or renal impairment (avoid if severe). Renal function should be continuously monitored during thiazide therapy. Thiazide diuretics may exacerbate or activate systemic lupus erythematosus in susceptible patients.

All thiazide diuretics can cause electrolyte imbalance, which is more severe, in patients with renal or hepatic impairment or in those receiving higher or prolonged doses. Serum electrolytes should be checked for abnormalities, particularly hypokalaemia, and the latter corrected by the addition of a potassium supplement to the regimen. Aggravates diabetes mellitus and gout; increased risk of hypomagnesaemia in alcoholic cirrhosis.

Caution is required when treating patients with porphyria. Patients taking pimozide or thioridazine. (see section 4.5)

This product contains the excipient lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.

Regular ongoing monitoring and blood tests are to be performed in elderly patients and patients who are on long term treatment with bendroflumethiazide.

4.5 Interaction with other medicinal products and other forms of interaction

•    Allopurinol: Bendroflumethiazide may antagonise the action of allopurinol by causing retention of urate in the kidney. Caution is advised when using this combination.

•    Anion exchange resins: Colestipol and colestyramine may reduce the absorption of thiazide diuretics and should therefore be given 2 hours prior to, or after the ingestion of B endroflumethiazide.

•    Anti-arrhythmics: The cardio toxicity of disopyramide, amiodarone, flecainide and quinidine is increased if hypokalaemia occurs. The action of lidocaine and mexiletine are antagonised by hypokalaemia.

•    Anti-depressants: There is an increased risk of postural hypotension if bendroflumethiazide is given with tricyclic antidepressants. There may be an risk of hypokalaemia if thiazides are given with reboxetine. Concomitant use with monoamine oxidase inhibitors (MAOIs), may result in an enhanced hypotensive effect.

•    Antidiabetics: Bendroflumethiazide antagonises the hypoglycaemic effects of sulfonylureas, with a potential loss of diabetic control

•    Anti-epileptics: Concomitant use of carbamazepine may increase the risk of hyponatraemia.

•    Anti-fungals: There is an increased risk of hyponatraemia if thiazides are given with amphotericin

•    Antihypertensives: Bendroflumethiazide may enhance the antihypertensive effect of ACE inhibitors and angiotensin-II antagonists.There is an increased risk of first dose hypotensive effect of post-synaptic alpha-blockers such as prazosin.

•    Antipsychotics: Hypokalaemia increases the risk of ventricular arrhythmias with pimozide or thioridazine; therefore, concomitant use should be avoided.

•    Calcium salts: Bendroflumethiazide reduces urinary excretion of calcium so there is an increase risk of hypercalcaemia when calcium salts are taken concurrently. Serum calcium levels should be monitored to ensure that they do not become excessive.

•    Calcium-channel blockers and peripheral vasodilators: The hypotensive effect of calcium channel blockers and moxisylyte may be enhanced when co-administered with bendroflumethiazide.

•    Corticosteroids: Corticosteroids may exacerbate hypokalaemia associated with bendroflumethiazide and its diuretic activity may be antagonised.

•    Cytotoxics: Concomitant use with cisplatin can lead to an increased risk of nephrotoxicity and ototoxicity.

•    Digoxin: Sensitivity to digitalis glycosides may be increased by the hypokalaemic effect of concurrent bendroflumethiazide. Patients should be observed for signs of digitalis intoxication, in particular arrhythmias, and if these appear, the dose of the digoxin should be temporarily reduced and a potassium supplement given to restore stability.

•    Hormone antagonists: There is an increased risk of hyponatraemia when thiazides (bendroflumethiazide) are used concomitantly with aminoglutethimide. Thiazides can cause an increased risk of hypercalcaemia when co-administered with toremifene.

•    Lithium:Bendroflumethiazide inhibits the tubular elimination of lithium, resulting in an elevated plasma lithium concentration and risk of toxicity. Plasma lithium concentrations must be monitored when these drugs are given concurrently.

•    Muscle relaxants: The hypotensive activity of bendroflumethiazide may be increased by baclofen and tizanidine.Thiazide diuretics may enhance the neuromuscular blocking effects of the non-depolarising muscle relaxants, e.g. tubocurarine, gallamine, alcuronium and pancuronium.

•    NSAIDs: Diuretics may increase the risk of nephrotoxicity of NSAIDs. Indometacin and ketorolac antagonise the diuretic effect of bendroflumethiazide, this occurs to a lesser extent with ibuprofen, piroxicam and naproxen. The effects of concurrent use should be monitored and the dose of bendroflumethiazide modified if necessary.

•    Oestrogens and progestogens: Oestrogens and combined oral contraceptives antagonise the diuretic effect of thiazides.

•    Vitamins: The risk of hypercalcaemia is increased if bendroflumethiazide is given with vitamin D preparations.

•    Sympathomimetics: Sympathomimetics can cause hypokalaemia. The risk of serious heart arrhythmias in asthmatic patients may be increased if bendroflumethiazide is added to their medication.

•    Theophylline: Concomitant administration of theophylline and bendroflumethiazide increases the risk of hypokalaemia.

•    Ulcer healing drugs: There is an increased risk of hypokalaemia and a decrease in diuretic activity when carbenoxolone and bendroflumethiazide are taken together. Patients should be monitored and given potassium supplements when required.

•    Terfenadine: Hypokalaemia or other electrolyte imbalance also increases the risk of ventricular arrhythmias with terfenadine.

•    Alcohol, barbiturates or opioids: Postural hypotension associated with therapy may be enhanced by concomitant ingestion of alcohol, barbiturates or opioid.

•    Laboratory tests: Bendroflumethiazide may interfere with a number of laboratory tests, including estimation of serum protein-bound iodine and tests of parathyroid function.

•    Others: Xanthines, beta-agonists, acetazolamide and ACTH may exacerbate the hypokalaemia associated with thiazide use.

4.6 Fertility, pregnancy and lactation

Diuretics (bendroflumethiazide) are best avoided for the management of oedema of pregnancy or hypertension in pregnancy as their use may be associated with hypokalaemia, increased blood viscosity and reduced placental perfusion.

There is insufficient evidence of safety in human pregnancy and foetal bone marrow depression and thrombocytopenia and neonatal jaundice have been described.

As diuretics pass into breast milk and Bendroflumethiazide can suppress lactation, although the amounts passing into breast milk are small, its use should be avoided in mothers who wish to breast feed.

4.7    Effects on ability to drive and use machines

Although Bendroflumethiazide may not affect driving ability directly, adverse events such as hypotension, dizziness etc may impact this ability. Therefore, patients experiencing such adverse events should take care not to drive or operate machinery.

4.8    Undesirable effects

The following undesirable effects, which are listed in system order class, have previously been associated with Bendroflumethiazide. Specific frequencies for the occurrence of these effects are not available.

Blood and lymphatic system disorders:

Rarely, blood dyscrasias including agranulocytosis, aplastic anaemia, neutropenia, thrombocytopenia (neonatal thrombocytosis is reported when given in late pregnancy) and leucopenia have been reported.

Immune system disorders: hypersensitivity reactions

Metabolism and nutrition disorders:

Bendroflumethiazide may lower carbohydrate tolerance and the insulin dosage of some diabetic patients may require adjustment.

Care is required when bendroflumethiazide is administered to patients with a known predisposition to diabetes (hyperglycaemia reported).

Bendroflumethiazide may raise serum uric acid levels and exacerbate gout in susceptible individuals (hyperuricaemia). Plasma lipids may be altered in patients taking bendroflumethiazide.

Cardiac and vascular disorders :

Postural hypotension

Respiratory, thoracic and mediastinal disorders:

Pneumonitis, pulmonary oedema

Gastrointestinal disorders:

Nausea, vomiting, diarrhoea, constipation and gastric irritation have all been reported

Hepatobiliary disorders:

Pancreatitis, intrahepatic cholestasis

Skin and subcutaneous tissue disorders:

Rash (including exfoliative dermatitis), photosensitivity, severe skin reactions also reported

Reproductive system and breast disorders:

Impotence (reversible on discontinuing the drug)

Investigations:

Hypokalaemia, hypomagnesaemia, hyponatraemia, hypercalcaemia, hypochloraemic alkalosis. Hypokalaemia may result in polyuria, malaise, muscle weakness or cramp, dizziness, nausea, anorexia or vomiting

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.

Overdose

Symptoms of overdosage include nausea, vomiting, diarrhoea, diuresis, dehydration, dizziness, weakness, muscle cramps, increased frequency of micturition with polyuria and thirst. Extreme cases may show depletion of intravascular volume, hypotension and peripheral circulatory failure. Mild hypoglycaemia and hypokalaemia are likely to be present if dieresis is profound.

CNS depression (eg drowsiness, lethargy and coma) may occur without cardiovascular or respiratory depression.

Treatment: Activated charcoal may help reduce absorption of substantial amounts if given within one hour of ingestion. Treatment should be symptomatic and directed at fluid and electrolyte replacement which should be monitored together with the blood pressure and renal function. Hyponatraemia should be treated with water deprivation rather than by the administration of sodium chloride. Cathartics should be avoided

5 PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: diuretic, ATC code: C03AA01 Bendroflumethiazide is a thiazide diuretic.

The mechanism whereby the thiazides exert their antihypertensive effect has not been clearly established.

Bendroflumethiazide inhibits the renal tubular absorption of salt and water by its action at the beginning of the distal convoluted tubule. Sodium and chloride ions are excreted in equivalent proportions. Because potassium excretion is promoted, metabolic alkalosis may occur secondary to hypokalaemia. There is no important effect upon carbonic anhydrase. Bendroflumethiazide exerts its diuretic effect in about 2 hours and this lasts for 12 to 18 hours or longer. The excretion of other electrolytes, notably potassium and magnesium, is also increased.

The excretion of calcium is reduced. Thiazides also reduce carbonic anhydrase activity so that bicarbonate excretion is increased, but this effect is generally small and does not appreciably alter the acid base balance or the pH of the urine. Thiazides also have a hypotensive effect, due to a reduction in peripheral resistance and enhance the effects of other antihypertensive agents.

5.2    Pharmacokinetic properties

Absorption: Bendroflumethiazide has been reported to be completely absorbed from the gastrointestinal tract and it is fairly extensively metabolised.. Diuresis is initiated in about 2 hours and lasts for 12-18 hours or longer About 30% is excreted unchanged in the urine. The onset of the hypotensive action is generally three or four days.

Distribution: Bendroflumethiazide is more than 90% bound to plasma proteins.

Metabolism: There are indications that it is fairly extensively metabolised. Peak plasma levels are reached in 2 hours and a plasma half- life of between 3 and 8.5 hours on average.

Elimination: About 30% is excreted unchanged in the urine with the remainder excreted as uncharacterized metabolites.

5.3    Preclinical safety data

Not applicable

6    PHARMACEUTICAL PARTICULARS

6.1    List of excipients

Anhydrous Lactose Talc

Pregelatinised starch Stearic acid

6.2    Incompatibilities

Not applicable.

6.3    Shelf life

PVC/PVDC Aluminium foil blisters: 3years HDPE containers: 18 months

6.4    Special precautions for storage

PVC/PVDC Aluminium foil blisters: Do not store above 25°C. Store in the original package HDPE containers: Do not store above 25°C. Keep the container tightly closed.

6.5    Nature and contents of container

PVC/PVDC Aluminium foil blister, pack sizes of 14, 28, 56, 84 tablets.

HDPE tablet containers, pack sizes of 50, 100, 250, 500, 1000 tablets Not all pack sizes may be marketed.

6.6    Special precautions for disposal

No special requirements

7    MARKETING AUTHORISATION HOLDER

Bristol Laboratories Limited Unit 3, Canalside Northbridge Road Berkhamsted HP4 1EG United Kingdom

8    MARKETING AUTHORISATION NUMBER(S)

PL 17907/0082

9    DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION 13/09/2011

10 DATE OF REVISION OF THE TEXT

03/02/2016