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Besitran 100mg Tablets

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0043/0044

30.05.14[25]


PATIENT INFORMATION LEAFLET

Lustral® 50 mg Tablets Lustral® 100 mg Tablets

(sertraline hydrochloride)

Read all of this leaflet carefully before you start taking this medicine.

-    Keep this leaflet. You may need to read it again.

-    If you have any further questions, ask your doctor or pharmacist.

-    This medicine has been prescribed for you. Do not pass it on to others.

It may harm them, even if their symptoms are the same as yours.

-    If any of the side effects gets serious, or if you notice any side effects not listed in this leaflet, please tell your doctor or pharmacist.

In this leaflet:

1.    What Lustral is and what it is used for.

2.    Before you take Lustral.

3.    How to take Lustral.

4.    Possible side effects.

5.    How to store Lustral.

6.    Further information.

This medicine is available using any of the above names but will be referred to as Lustral throughout this leaflet.

1. What Lustral is and what it is used for

Lustral contains the active ingredient sertraline. Sertraline is one of a group of medicines called Selective Serotonin Re-uptake Inhibitors (SSRIs); these medicines are used to treat depression and/or anxiety disorders.

Lustral can be used to treat:

-    Depression and prevention of recurrence of depression (in adults).

-    Social anxiety disorder (in adults).

-    Post traumatic stress disorder (PTSD) (in adults).

-    Panic disorder (in adults).

-    Obsessive compulsive disorder (OCD) (in adults and children and adolescents aged 6-17 years old).

Depression is a clinical illness with symptoms like feeling sad, unable to sleep properly or to enjoy life as you used to.

OCD and Panic disorders are illnesses linked to anxiety with symptoms like being constantly troubled by persistent ideas (obsessions) that make you carry out repetitive rituals (compulsions).

PTSD is a condition that can occur after a very emotionally traumatic experience, and has some symptoms that are similar to depression and anxiety. Social anxiety disorder (social phobia) is an illness linked to anxiety. It is characterised by feelings of intense anxiety or distress in social situations (for example: talking to strangers, speaking in front of groups of people, eating or drinking in front of others or worrying that you might behave in an embarrassing manner).

Your doctor has decided that this medicine is suitable for treating your illness.

You should ask your doctor if you are unsure why you have been given Lustral.

2. Before you take Lustral Do not take Lustral:

-    If you are allergic (hypersensitive) to sertraline or any of the other ingredients of Lustral (see 6. Further Information for a list of ingredients).

-    If you are taking or have taken medicines called monoamine oxidase inhibitors (MAOIs such as selegiline, moclobemide) or MAOI like drugs (such as linezolid). If you stop treatment with sertraline, you must wait until at least one week before you start treatment with a MAOI.

After stopping treatment with a MAOI, you must wait at least 2 weeks before you can start treatment with sertraline.

-    If you are taking another medicine called Pimozide (a medicine for mental disorders such as psychosis).

Take special care with Lustral:

Medicines are not always suitable for everyone. Tell your doctor before you take Lustral, if you suffer from or have suffered in the past from any of the following conditions:

-    Epilepsy or a history of seizures. If you have a fit (seizure), contact your doctor immediately.

-    If you have suffered from manic depressive illness (bipolar disorder) or schizophrenia. If you have a manic episode, contact your doctor immediately.

-    If you have or have previously had thoughts of harming or killing yourself (see below-Thoughts of suicide and worsening of your depression or anxiety disorder).

-    Serotonin Syndrome. In rare cases this syndrome may occur when you are taking certain medicines at the same time as sertraline. (For symptoms, see section 4. Possible Side Effects). Your doctor will have told you whether you have suffered from this in the past.

-    If you have low sodium level in your blood, since this can occur as a result of treatment with Lustral. You should also tell your doctor if you are taking certain medicines for hypertension, since these medicines may also alter the sodium level in your blood.

-    Take special care if you are elderly as you may be more at risk of having low sodium level in your blood (see above).

-    Liver disease; your doctor may decide that you should have a lower dose of Lustral.

-    Diabetes; your blood glucose levels may be altered due to Lustral and your diabetes medicines may need to be adjusted.

-    If you have suffered from bleeding disorders or have been taking medicines which thin the blood (e.g. acetylsalicyclic acid (aspirin), or warfarin) or may increase the risk of bleeding.

-    If you are a child or adolescent under 18 years old.

Lustral should only be used to treat children and adolescents aged 6-17 years old, suffering from obsessive compulsive disorder (OCD). If you are being treated for this disorder, your doctor will want to monitor you closely (see below - Use in children and adolescents).

-    If you are having electro-convulsive therapy (ECT).

-    If you have eye problems, such as certain kinds of glaucoma (increased pressure in the eye).

Restlessness/Akathisia:

The use of sertraline has been linked to a distressing restlessness and need to move, often being unable to sit or stand still (akathisia). This is most likely to occur during the first few weeks of treatment. Increasing the dose may be harmful so if you develop such symptoms you should talk to your doctor.

Withdrawal reactions:

Side effects relating to stopping treatment (withdrawal reactions) are common, particularly if the treatment is stopped suddenly (see section 3 If you stop taking Lustral and section 4 Possible side effects). The risk of withdrawal symptoms depends on the length of treatment, dosage, and the rate at which the dose is reduced. Generally, such symptoms are mild to moderate. However, they can be serious in some patients.

They normally occur within the first few days after stopping treatment. In general, such symptoms disappear on their own and wear off within 2 weeks. In some patients they may last longer (2-3 months or more).

When stopping treatment with sertraline it is recommended to reduce the dose gradually over a period of several weeks or months, and you should always discuss the best way of stopping treatment with your doctor.

Thoughts of suicide and worsening of your depression or anxiety disorder:

If you are depressed and/or have anxiety disorders you can sometimes have thoughts of harming or killing yourself.

These may be increased when first starting antidepressants, since these medicines all take time to work, usually about two weeks but sometimes longer.

You may be more likely to think like this:

-    If you have previously had thoughts about killing or harming yourself.

-    If you are a young adult. Information from clinical trials has shown an increased risk of suicidal behaviour in adults aged less than 25 years with psychiatric conditions who were treated with an antidepressant.

If you have thoughts of harming or killing yourself at any time, contact your doctor or go to a hospital straight away.

You may find it helpful to tell a relative or close friend that you are depressed or have an anxiety disorder, and ask them to read this leaflet. You might ask them to tell you if they think your depression or anxiety is getting worse, or if they are worried about changes in your behaviour.

Use in children and adolescents:

Sertraline should not usually be used in children and adolescents less than 18 years old, except for patients with Obsessive Compulsive Disorder (OCD). Patients under 18 have an increased risk of undesirable effects, such as suicide attempt, thoughts of harming or killing themselves (suicidal thoughts) and hostility (mainly aggressiveness, oppositional behaviour and anger) when they are treated with this class of medicines. Nevertheless, it is possible that your doctor decides to prescribe Lustral to a patient under 18 if it is in the patient's interest. If your doctor has prescribed Lustral to you and you are less than 18 years old and you want to discuss this, please contact him/her. Furthermore, if any of the symptoms listed above appear or worsen while you are taking Lustral, you should inform your doctor. Also, the long-term safety of Lustral in regard to growth, maturation and learning (cognitive) and behavioural development in this age group has not yet been demonstrated.

Taking other medicines:

Please tell your doctor if you are taking or have recently taken any other medicines, including medicines obtained without a prescription.

Some medicines can affect the way Lustral works, or Lustral itself can reduce the effectiveness of other medicines taken at the same time.

Taking Lustral together with the following medicines may cause serious side effects:

-    Medicines called monoamine oxidase inhibitors (MAOIs), like moclobemide (to treat depression) and selegiline (to treat Parkinson's disease), the antibiotic linezolid and methylene blue (to treat high levels of methaemoglobin in the blood). Do not use Lustral together with these medicines.

-    Medicines to treat mental disorders such as psychosis (pimozide).

Do not use Lustral together with pimozide.

Talk to your doctor if you are taking the following medicine:

-    Herbal medicine containing St. John's Wort (Hypericum perforatum). The effects of St. John's Wort may last for 1-2 weeks.

-    Products containing the amino acid tryptophan.

-    Medicines to treat severe pain (e.g. tramadol).

-    Medicines used in anaesthesia or to treat chronic pain (fentanyl).

-    Medicines to treat migraines (e.g. sumatriptan).

-    Blood thinning medicine (warfarin).

-    Medicines to treat pain/arthritis (Non steroidal anti-inflammatory drug (NSAID) such as ibuprofen, acetylsalicylic acid (aspirin).

-    Sedatives (diazepam).

-    Diuretics (also called ‘water' tablets).

-    Medicines to treat epilepsy (phenytoin, phenobarbital, carbamazepine).

-    Medicines to treat diabetes (tolbutamide).

-    Medicines to treat excessive stomach acid, ulcers and heartburn (cimetidine, omeprazole, lanzoprazole, pantoprazole, rabeprazole).

-    Medicines to treat mania and depression (lithium).

-    Other medicines to treat depression (such as amitriptyline, nortriptyline, nefazodone, fluoxetine, fluvoxamine).

-    Medicines to treat schizophrenia and other mental disorders (such as perphenazine, levomepromazine and olanzapine).

-    Medicines used to treat high blood pressure, chest pain or regulate the rate and rhythm of the heart (such as verapamil, diltiazem, flecainide, propafenone).

-    Medicines used to treat bacterial infections (such as rifampicin, clarithromycin, telithromycin, erythromycin).

-    Medicines used to treat fungal infections (such as ketoconazole, itraconazole, posaconazole, voriconazole, fluconazole).

-    Medicines used to treat HIV/AIDS and Hepatitis C (protease inhibitors such as ritonavir, telaprevir).

-    Medicines used to prevent nausea and vomiting after an operation or chemotherapy (aprepitant).

Taking Lustral with food and drink:

Lustral tablets can be taken with or without food.

Alcohol should be avoided whilst taking Lustral.

Sertraline should not be taken in combination with grapefruit juice, as this may increase the level of sertraline in your body.

Pregnancy, breast-feeding and fertility:

Ask your doctor or pharmacist for advice before taking any medicine.

The safety of sertraline has not fully been established in pregnant women. Sertraline will only be given to you when pregnant if your doctor considers that the benefit for you is greater than any possible risk to the developing baby. If you are a woman capable of having children you should use a reliable method of contraception (such as the contraceptive pill), when taking sertraline.

Make sure your midwife and/or doctor know you are on Lustral. When taken during pregnancy, particularly in the last 3 months of pregnancy, medicines like Lustral may increase the risk of a serious condition in babies, called persistent pulmonary hypertension of the newborn (PPHN), making the baby breathe faster and appear bluish. These symptoms usually begin during the first 24 hours after the baby is born. If this happens to your baby you should contact your midwife and/or doctor immediately.

Your newborn baby might also have other conditions, which usually begin during the first 24 hours after birth. Symptoms include:

-    trouble with breathing,

-    a blueish skin or being too hot or cold,

-    blue lips,

-    vomiting or not feeding properly,

-    being very tired, not able to sleep or crying a lot,

-    stiff or floppy muscles,

-    tremors, jitters or fits,

-    increased reflex reactions,

-    irritability,

-    low blood sugar.

If your baby has any of these symptoms when it is born, or you are concerned about your baby’s health, contact your doctor or midwife who will be able to advise you.

There is evidence that sertraline passes into human breast milk. Sertraline should only be used in women during breast-feeding, if your doctor considers that the benefit exceeds any possible risk to the baby.

Some medicines like sertraline may reduce the quality of sperm in animal studies. Theoretically, this could affect fertility, but impact on human fertility has not been observed as yet.

Driving and using machines:

Psychotropic drugs such as sertraline may influence your ability to drive or use machines. You should therefore not drive or operate machinery, until you know how this medication affects your ability to perform these activities.

3.    How to take Lustral

Always take Lustral exactly as your doctor has told you.

Lustral tablets may be taken with or without food.

Take your medication once daily either in the morning or evening.

You should check with your doctor or pharmacist if you are not sure.

The usual dose is:

Adults:

Depression and Obsessive Compulsive Disorder

For depression and OCD, the usual effective dose is 50 mg/day. The daily dose may be increased in 50 mg increments and at intervals of at least one week over a period of weeks. The maximum recommended dose is 200 mg/day.

Panic disorder, Social anxiety disorder and Post Traumatic Stress Disorder:

For panic disorder, social anxiety disorder and post traumatic stress disorder, treatment should be started at 25 mg/day, and increased to 50 mg/day after one week.

The daily dose then may be increased in 50 mg increments over a period of weeks. The maximum recommended dose is 200 mg/day.

Children and adolescents:

Lustral must only be used to treat children and adolescents suffering from OCD aged 6-17 years old.

Obsessive Compulsive Disorder:

Children aged 6 to 12: the recommended starting dose is 25 mg daily. After one week, your doctor may increase this to 50 mg daily. The maximum dose is 200 mg daily.

Adolescents aged 13 to 17: the recommended starting dose is 50 mg daily.

The maximum dose is 200 mg daily.

If you have liver or kidney problems, please tell your doctor and follow the doctor's instructions.

Your doctor will advise you on how long to take this medication for. This will depend on the nature of your illness and how well you are responding to the treatment. It may take several weeks before your symptoms begin to improve. Treatment of depression should usually continue for 6 months after improvement.

If you take more Lustral than you should:

If you accidentally take too much Lustral contact your doctor at once or go to the nearest hospital casualty department.

Always take the labelled medicine package with you, whether there is any medication left or not.

Symptoms of overdose may include drowsiness, nausea and vomiting, rapid heart rate, shaking, agitation, dizziness and in rare cases unconsciousness.

If you forget to take Lustral:

If you forget to take a dose, do not take the missed dose.

Just take the next dose at the right time.

Do not take a double dose to make up for a forgotten dose.

If you stop taking Lustral:

Do not stop taking Lustral unless your doctor tells you to.

Your doctor will want to gradually reduce your dose of Lustral over several weeks, before you finally stop taking this medicine. If you suddenly stop taking this medicine you may experience side effects such as dizziness, numbness, sleep disturbances, agitation or anxiety, headaches, feeling sick, being sick and shaking. If you experience any of these side effects, or any other side effects whilst stopping taking Lustral, please speak to your doctor.

If you have any further questions on the use of this product, ask your doctor or pharmacist.

4.    Possible side effects

Like all medicines, Lustral can cause side effects, although not everybody gets them.

If any of the side effects gets serious, or if you notice any side effects not listed in this leaflet, please tell your doctor or pharmacist.

Nausea is the most common side effect. The side effects depend on the dose and often disappear or lessen with continued treatment.

Tell your doctor immediately:

If you experience any of the following symptoms after taking this medicine, these symptoms can be serious.

-    If you develop a severe skin rash that causes blistering (erythema multiforme), (this can affect the mouth and tongue). These may be signs of a condition known as Stevens Johnson Syndrome, or Toxic Epidermal Necrolysis (TEN). Your doctor will stop your treatment in these cases.

-    Allergic reaction or allergy, which may include symptoms such as an itchy skin rash, breathing problems, wheezing, swollen eyelids, face or lips.

-    If you experience agitation, confusion, diarrhoea, high temperature and blood pressure, excessive sweating and rapid heartbeat. These are symptoms of Serotonin Syndrome. In rare cases this syndrome may occur when you are taking certain medicines at the same time as sertraline. Your doctor may wish to stop your treatment.

-    If you develop yellow skin and eyes which may mean liver damage.

-    If you experience depressive symptoms with ideas of harming or killing yourself (suicidal thoughts).

-    If you start to get feelings of restlessness and are not able to sit or stand still after you start to take Lustral.

You should tell your doctor if you start to feel restless.

-    If you have a fit (seizure).

-    If you have a manic episode (see section 2 “Take special care with Lustral”).

Lustral 50 mg Tablets PL 15361/0043 Lustral 100 mg Tablets PL 15361/0044


The following side effects were seen in clinical trials in adults.

Very common side effects (occurs in more than 1 out of 10 patients):

Insomnia, dizziness, sleepiness, headache, diarrhoea, feeling sick, dry mouth, ejaculation failure, fatigue.

Common side effects (occurs in between 1 and 10 out of 100 patients):

-    Sore throat, anorexia, increased appetite,

-    depression, feeling strange, nightmare, anxiety, agitation, nervousness, decreased sexual interest, teeth grinding,

-    numbness and tingling, shaking, muscle tense, abnormal taste, lack of attention,

-    visual disturbance, ringing in ears,

-    palpitations, hot flush, yawning,

-    abdominal pain, vomiting, constipation, upset stomach, gas,

-    rash, increased sweating, muscle pain, erectile dysfunction, chest pain.

-    joint pain,

-    Malaise.

Uncommon side effects (occurs in between 1 and 10 out of 1.000 patients):

-    Chest cold, runny nose,

-    hypersensitivity,

-    low thyroid hormones,

-    hallucination, feeling too happy, lack of caring, thinking abnormal, aggression,

-    convulsion, involuntary muscle contractions, abnormal coordination, moving a lot, amnesia, decreased feeling, speech disorder, dizziness while standing up, passing out, migraine,

-    enlarged pupils,

-    ear pain, fast heartbeat, high blood pressure, flushing,

-    breathing difficulty, possible wheezing, shortness of breath, nose bleed,

-    inflammation of the oesophagus, difficulty swallowing, haemorrhoids, increased saliva, tongue disorder, burping,

-    eye swelling, purple spots on skin, face oedema, hair loss, cold sweat, dry skin, hives, itching,

-    osteoarthritis, muscular weakness, back pain, muscle twitching,

-    nighttime urination, unable to urinate, increase in urination, increase in frequency of urination, problem urinating, urinary incontinence,

-    vaginal haemorrhage, sexual dysfunction, female sexual dysfunction, menstrual irregularities, swelling in legs, chills, fever, weakness, thirst, increase in liver enzyme levels, weight decreased, weight increased.

Rare side effects (occurs in between 1 and 10 out of 10.000 patients):

-    Intestine problem, ear infection, cancer, swollen glands, high cholesterol, low blood sugar,

-    physical symptoms due to stress or emotions, drug dependence, psychotic disorder, paranoia, suicidal thoughts, sleep walking, premature ejaculation,

-    severe allergic reaction,

-    coma, abnormal movements, difficulty moving, increased sensation, sensory disturbance,

-    glaucoma, tear problem, spots in front of eyes, double vision, light hurts eye, blood in the eye,

-    problems controlling blood sugar levels (diabetes),

-    heart attack, slow heart beat, heart problem, poor circulation of arms and legs, closing up of throat, breathing fast, breathing slow, difficulty talking, hiccups,

-    blood in stool, sore mouth, tongue ulceration, tooth disorder, tongue problem, mouth ulceration, problems with liver function,

-    skin problem with blisters, hair rash, hair texture abnormal, skin odour abnormal, bone disorder,

-    decreased urination, urinary hesitation, blood in urine,

-    excessive vaginal bleeding, dry vaginal area, red painful penis and foreskin, genital discharge, prolonged erection, breast discharge,

-    hernia, drug tolerance decreased, difficulty walking, semen abnormal, increase in blood cholesterol levels, injury, relaxation of blood vessels procedure.

-    Cases of suicidal ideation and suicidal behaviours have been reported during sertraline therapy or early after treatment discontinuation (see section 2.).

After marketing sertraline, the following side effects have been reported:

-    Decrease in white blood cells, decrease in clotting cells, endocrine problem, low blood salt, increase in blood sugar levels,

-    terrifying abnormal dreams, suicidal behaviour,

-    muscular movement problems (such as moving a lot, tense muscles, difficulty walking and stiffness, spasms and involuntary movements of the muscles), sudden severe headache (which may be a sign of a serious condition known as Reversible Cerebral Vasoconstriction Syndrome (RCVS)),

-    vision abnormal, unequal sized pupils, bleeding problems (such as stomach bleeding), progressive scarring of lung tissue (Interstitial Lung Disease), pancreatitis, serious liver function problems, yellow skin and eyes (jaundice),

-    skin oedema, skin reaction to sun, muscle cramps, breast enlargement, problems with clotting, bedwetting.

Side effects in children and adolescents

In clinical trials with children and adolescents, the side effects were generally similar to adults (see above). The most common side effects in children and adolescents were headache, insomnia, diarrhoea and feeling sick.

Symptoms that can occur when treatment is discontinued

If you suddenly stop taking this medicine you may experience side effects such as dizziness, numbness, sleep disturbances, agitation or anxiety, headaches, feeling sick, being sick and shaking (see section 3. “If you stop taking Lustral”).

An increased risk of bone fractures has been observed in patients taking this type of medicines.

Reporting of side effects

If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any possible side effects not listed in this leaflet. You can also report side effects directly via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.

By reporting side effects, you can help provide more information on the safety of this medicine.

5. How to store Lustral

Keep out of the sight and reach of children.

Store below 30oC.

Do not use Lustral after the expiry date which is stated on the pack. The expiry date refers to the last day of that month.

Medicines should not be disposed of via wastewater or household waste. Ask your pharmacist how to dispose of medicines no longer required. These measures will help to protect the environment.

What Lustral contains

The active substance is sertraline hydrochloride.

Lustral 50mg Tablets contains 50mg of sertraline (as hydrochloride) Lustral 100mg Tablets contains 100mg of sertraline (as hydrochloride)

Other ingredients: calcium hydrogen phosphate, hydroxypropylcellulose, hydroxypropylmethylcellulose, magnesium stearate, microcrystalline cellulose, polyethylene glycol, polysorbate-80, sodium starch glycollate, and titanium dioxide.

What Lustral looks like and contents of the pack

Lustral 50 mg Tablets are white capsular shaped with the markings “ZLT” AND “50” on one side and “Pfizer” on the other side.

Lustral 100 mg Tablets are white capsular shaped with the markings “ZLT” AND “100” on one side and “Pfizer” on the other side.

Each pack contains 30 tablets.

Manufacturer and Product Licence Holder

Manufactured by Farmasierra Manufacturing S.L., San Sebastian de los Reyes, Madrid, Spain. Procured from within the EU and Repackaged by the Product Licence holder P.I.E. Pharma Ltd, 207 Kenton Road, Harrow, Middlesex HA3 0HD.

Leaflet issue and revision date (Ref.) 30.05.14[25] Lustral® is a trademark of Pfizer Products lnc.

6. Further information

PATIENT INFORMATION LEAFLET    0043/0044

30.05.14[25]

Besitran™ 50 mg Tablets /

Sertraline 50 mg Tablets Besitran™ 100 mg Tablets /

Sertraline 100 mg Tablets

(sertraline hydrochloride)

Read all of this leaflet carefully before you start taking this medicine.

-    Keep this leaflet. You may need to read it again.

-    If you have any further questions, ask your doctor or pharmacist.

-    This medicine has been prescribed for you. Do not pass it on to others.

It may harm them, even if their symptoms are the same as yours.

-    If any of the side effects gets serious, or if you notice any side effects not listed in this leaflet, please tell your doctor or pharmacist.

In this leaflet:

1.    What Besitran is and what it is used for.

2.    Before you take Besitran.

3.    How to take Besitran.

4.    Possible side effects.

5.    How to store Besitran.

6.    Further information.

This medicine is available using any of the above names but will be referred to as Besitran throughout this leaflet.

1.    What Besitran is and what it is used for

Besitran contains the active ingredient sertraline. Sertraline is one of a group of medicines called Selective Serotonin Re-uptake Inhibitors (SSRIs); these medicines are used to treat depression and/or anxiety disorders.

Besitran can be used to treat:

-    Depression and prevention of recurrence of depression (in adults).

-    Social anxiety disorder (in adults).

-    Post traumatic stress disorder (PTSD) (in adults).

-    Panic disorder (in adults).

-    Obsessive compulsive disorder (OCD) (in adults and children and adolescents aged 6-17 years old).

Depression is a clinical illness with symptoms like feeling sad, unable to sleep properly or to enjoy life as you used to.

OCD and Panic disorders are illnesses linked to anxiety with symptoms like being constantly troubled by persistent ideas (obsessions) that make you carry out repetitive rituals (compulsions).

PTSD is a condition that can occur after a very emotionally traumatic experience, and has some symptoms that are similar to depression and anxiety. Social anxiety disorder (social phobia) is an illness linked to anxiety. It is characterised by feelings of intense anxiety or distress in social situations (for example: talking to strangers, speaking in front of groups of people, eating or drinking in front of others or worrying that you might behave in an embarrassing manner).

Your doctor has decided that this medicine is suitable for treating your illness.

You should ask your doctor if you are unsure why you have been given Besitran.

2.    Before you take Besitran Do not take Besitran:

-    If you are allergic (hypersensitive) to sertraline or any of the other ingredients of Besitran (see 6. Further Information for a list of ingredients).

-    If you are taking or have taken medicines called monoamine oxidase inhibitors (MAOIs such as selegiline, moclobemide) or MAOI like drugs (such as linezolid). If you stop treatment with sertraline, you must wait until at least one week before you start treatment with a MAOI.

After stopping treatment with a MAOI, you must wait at least 2 weeks before you can start treatment with sertraline.

-    If you are taking another medicine called Pimozide (a medicine for mental disorders such as psychosis).

Take special care with Besitran:

Medicines are not always suitable for everyone. Tell your doctor before you take Besitran, if you suffer from or have suffered in the past from any of the following conditions:

-    Epilepsy or a history of seizures. If you have a fit (seizure), contact your doctor immediately.

-    If you have suffered from manic depressive illness (bipolar disorder) or schizophrenia. If you have a manic episode, contact your doctor immediately.

-    If you have or have previously had thoughts of harming or killing yourself (see below-Thoughts of suicide and worsening of your depression or anxiety disorder).

-    Serotonin Syndrome. In rare cases this syndrome may occur when you are taking certain medicines at the same time as sertraline. (For symptoms, see section 4. Possible Side Effects). Your doctor will have told you whether you have suffered from this in the past.

-    If you have low sodium level in your blood, since this can occur as a result of treatment with Besitran. You should also tell your doctor if you are taking certain medicines for hypertension, since these medicines may also alter the sodium level in your blood.

-    Take special care if you are elderly as you may be more at risk of having low sodium level in your blood (see above).

-    Liver disease; your doctor may decide that you should have a lower dose of Besitran.

-    Diabetes; your blood glucose levels may be altered due to Besitran and your diabetes medicines may need to be adjusted.

-    If you have suffered from bleeding disorders or have been taking medicines which thin the blood (e.g. acetylsalicyclic acid (aspirin), or warfarin) or may increase the risk of bleeding.

-    If you are a child or adolescent under 18 years old.

Besitran should only be used to treat children and adolescents aged 617 years old, suffering from obsessive compulsive disorder (OCD). If you are being treated for this disorder, your doctor will want to monitor you closely (see below - Use in children and adolescents).

-    If you are having electro-convulsive therapy (ECT).

-    If you have eye problems, such as certain kinds of glaucoma (increased pressure in the eye).

Restlessness/Akathisia:

The use of sertraline has been linked to a distressing restlessness and need to move, often being unable to sit or stand still (akathisia). This is most likely to occur during the first few weeks of treatment. Increasing the dose may be harmful so if you develop such symptoms you should talk to your doctor.

Withdrawal reactions:

Side effects relating to stopping treatment (withdrawal reactions) are common, particularly if the treatment is stopped suddenly (see section 3 If you stop taking Besitran and section 4 Possible side effects). The risk of withdrawal symptoms depends on the length of treatment, dosage, and the rate at which the dose is reduced. Generally, such symptoms are mild to moderate. However, they can be serious in some patients.

They normally occur within the first few days after stopping treatment. In general, such symptoms disappear on their own and wear off within 2 weeks. In some patients they may last longer (2-3 months or more).

When stopping treatment with sertraline it is recommended to reduce the dose gradually over a period of several weeks or months, and you should always discuss the best way of stopping treatment with your doctor.

Thoughts of suicide and worsening of your depression or anxiety disorder:

If you are depressed and/or have anxiety disorders you can sometimes have thoughts of harming or killing yourself.

These may be increased when first starting antidepressants, since these medicines all take time to work, usually about two weeks but sometimes longer.

You may be more likely to think like this:

-    If you have previously had thoughts about killing or harming yourself.

-    If you are a young adult. Information from clinical trials has shown an increased risk of suicidal behaviour in adults aged less than 25 years with psychiatric conditions who were treated with an antidepressant.

If you have thoughts of harming or killing yourself at any time, contact your doctor or go to a hospital straight away.

You may find it helpful to tell a relative or close friend that you are depressed or have an anxiety disorder, and ask them to read this leaflet. You might ask them to tell you if they think your depression or anxiety is getting worse, or if they are worried about changes in your behaviour.

Use in children and adolescents:

Sertraline should not usually be used in children and adolescents less than 18 years old, except for patients with Obsessive Compulsive Disorder (OCD). Patients under 18 have an increased risk of undesirable effects, such as suicide attempt, thoughts of harming or killing themselves (suicidal thoughts) and hostility (mainly aggressiveness, oppositional behaviour and anger) when they are treated with this class of medicines. Nevertheless, it is possible that your doctor decides to prescribe Besitran to a patient under 18 if it is in the patient's interest. If your doctor has prescribed Besitran to you and you are less than 18 years old and you want to discuss this, please contact him/her. Furthermore, if any of the symptoms listed above appear or worsen while you are taking Besitran, you should inform your doctor. Also, the long-term safety of Besitran in regard to growth, maturation and learning (cognitive) and behavioural development in this age group has not yet been demonstrated.

Taking other medicines:

Please tell your doctor if you are taking or have recently taken any other medicines, including medicines obtained without a prescription.

Some medicines can affect the way Besitran works, or Besitran itself can reduce the effectiveness of other medicines taken at the same time.

Taking Besitran together with the following medicines may cause serious side effects:

-    Medicines called monoamine oxidase inhibitors (MAOIs), like moclobemide (to treat depression) and selegiline (to treat Parkinson's disease), the antibiotic linezolid and methylene blue (to treat high levels of methaemoglobin in the blood). Do not use Besitran together with these medicines.

-    Medicines to treat mental disorders such as psychosis (pimozide).

Do not use Besitran together with pimozide.

Talk to your doctor if you are taking the following medicine:

-    Herbal medicine containing St. John's Wort (Hypericum perforatum). The effects of St. John's Wort may last for 1-2 weeks.

-    Products containing the amino acid tryptophan.

-    Medicines to treat severe pain (e.g. tramadol).

-    Medicines used in anaesthesia or to treat chronic pain (fentanyl).

-    Medicines to treat migraines (e.g. sumatriptan).

-    Blood thinning medicine (warfarin).

-    Medicines to treat pain/arthritis (Non steroidal anti-inflammatory drug (NSAID) such as ibuprofen, acetylsalicylic acid (aspirin).

-    Sedatives (diazepam).

-    Diuretics (also called ‘water' tablets).

-    Medicines to treat epilepsy (phenytoin, phenobarbital, carbamazepine).

-    Medicines to treat diabetes (tolbutamide).

-    Medicines to treat excessive stomach acid, ulcers and heartburn (cimetidine, omeprazole, lanzoprazole, pantoprazole, rabeprazole).

-    Medicines to treat mania and depression (lithium).

-    Other medicines to treat depression (such as amitriptyline, nortriptyline, nefazodone, fluoxetine, fluvoxamine).

-    Medicines to treat schizophrenia and other mental disorders (such as perphenazine, levomepromazine and olanzapine).

-    Medicines used to treat high blood pressure, chest pain or regulate the rate and rhythm of the heart (such as verapamil, diltiazem, flecainide, propafenone).

-    Medicines used to treat bacterial infections (such as rifampicin, clarithromycin, telithromycin, erythromycin).

-    Medicines used to treat fungal infections (such as ketoconazole, itraconazole, posaconazole, voriconazole, fluconazole).

-    Medicines used to treat HIV/AIDS and Hepatitis C (protease inhibitors such as ritonavir, telaprevir).

-    Medicines used to prevent nausea and vomiting after an operation or chemotherapy (aprepitant).

Taking Besitran with food and drink:

Besitran tablets can be taken with or without food.

Alcohol should be avoided whilst taking Besitran.

Sertraline should not be taken in combination with grapefruit juice, as this may increase the level of sertraline in your body.

Pregnancy, breast-feeding and fertility:

Ask your doctor or pharmacist for advice before taking any medicine.

The safety of sertraline has not fully been established in pregnant women. Sertraline will only be given to you when pregnant if your doctor considers that the benefit for you is greater than any possible risk to the developing baby. If you are a woman capable of having children you should use a reliable method of contraception (such as the contraceptive pill), when taking sertraline.

Make sure your midwife and/or doctor know you are on Besitran. When taken during pregnancy, particularly in the last 3 months of pregnancy, medicines like Besitran may increase the risk of a serious condition in babies, called persistent pulmonary hypertension of the newborn (PPHN), making the baby breathe faster and appear bluish. These symptoms usually begin during the first 24 hours after the baby is born. If this happens to your baby you should contact your midwife and/or doctor immediately.

Your newborn baby might also have other conditions, which usually begin during the first 24 hours after birth. Symptoms include:

-    trouble with breathing,

-    a blueish skin or being too hot or cold,

-    blue lips,

-    vomiting or not feeding properly,

-    being very tired, not able to sleep or crying a lot,

-    stiff or floppy muscles,

-    tremors, jitters or fits,

-    increased reflex reactions,

-    irritability,

-    low blood sugar.

If your baby has any of these symptoms when it is born, or you are concerned about your baby’s health, contact your doctor or midwife who will be able to advise you.

There is evidence that sertraline passes into human breast milk. Sertraline should only be used in women during breast-feeding, if your doctor considers that the benefit exceeds any possible risk to the baby.

Some medicines like sertraline may reduce the quality of sperm in animal studies. Theoretically, this could affect fertility, but impact on human fertility has not been observed as yet.

Driving and using machines:

Psychotropic drugs such as sertraline may influence your ability to drive or use machines. You should therefore not drive or operate machinery, until you know how this medication affects your ability to perform these activities.

3.    How to take Besitran

Always take Besitran exactly as your doctor has told you.

Besitran tablets may be taken with or without food.

Take your medication once daily either in the morning or evening.

You should check with your doctor or pharmacist if you are not sure.

The usual dose is:

Adults:

Depression and Obsessive Compulsive Disorder

For depression and OCD, the usual effective dose is 50 mg/day. The daily dose may be increased in 50 mg increments and at intervals of at least one week over a period of weeks. The maximum recommended dose is 200 mg/day.

Panic disorder, Social anxiety disorder and Post Traumatic Stress Disorder:

For panic disorder, social anxiety disorder and post traumatic stress disorder, treatment should be started at 25 mg/day, and increased to 50 mg/day after one week.

The daily dose then may be increased in 50 mg increments over a period of weeks. The maximum recommended dose is 200 mg/day.

Children and adolescents:

Besitran must only be used to treat children and adolescents suffering from OCD aged 6-17 years old.

Obsessive Compulsive Disorder:

Children aged 6 to 12: the recommended starting dose is 25 mg daily. After one week, your doctor may increase this to 50 mg daily. The maximum dose is 200 mg daily.

Adolescents aged 13 to 17: the recommended starting dose is 50 mg daily.

The maximum dose is 200 mg daily.

If you have liver or kidney problems, please tell your doctor and follow the doctor's instructions.

Your doctor will advise you on how long to take this medication for. This will depend on the nature of your illness and how well you are responding to the treatment. It may take several weeks before your symptoms begin to improve. Treatment of depression should usually continue for 6 months after improvement.

If you take more Besitran than you should:

If you accidentally take too much Besitran contact your doctor at once or go to the nearest hospital casualty department.

Always take the labelled medicine package with you, whether there is any medication left or not.

Symptoms of overdose may include drowsiness, nausea and vomiting, rapid heart rate, shaking, agitation, dizziness and in rare cases unconsciousness.

If you forget to take Besitran:

If you forget to take a dose, do not take the missed dose.

Just take the next dose at the right time.

Do not take a double dose to make up for a forgotten dose.

If you stop taking Besitran:

Do not stop taking Besitran unless your doctor tells you to.

Your doctor will want to gradually reduce your dose of Besitran over several weeks, before you finally stop taking this medicine. If you suddenly stop taking this medicine you may experience side effects such as dizziness, numbness, sleep disturbances, agitation or anxiety, headaches, feeling sick, being sick and shaking. If you experience any of these side effects, or any other side effects whilst stopping taking Besitran, please speak to your doctor.

If you have any further questions on the use of this product, ask your doctor or pharmacist.

4.    Possible side effects

Like all medicines, Besitran can cause side effects, although not everybody gets them.

If any of the side effects gets serious, or if you notice any side effects not listed in this leaflet, please tell your doctor or pharmacist.

Nausea is the most common side effect. The side effects depend on the dose and often disappear or lessen with continued treatment.

Tell your doctor immediately:

If you experience any of the following symptoms after taking this medicine, these symptoms can be serious.

-    If you develop a severe skin rash that causes blistering (erythema multiforme), (this can affect the mouth and tongue). These may be signs of a condition known as Stevens Johnson Syndrome, or Toxic Epidermal Necrolysis (TEN). Your doctor will stop your treatment in these cases.

-    Allergic reaction or allergy, which may include symptoms such as an itchy skin rash, breathing problems, wheezing, swollen eyelids, face or lips.

-    If you experience agitation, confusion, diarrhoea, high temperature and blood pressure, excessive sweating and rapid heartbeat. These are symptoms of Serotonin Syndrome. In rare cases this syndrome may occur when you are taking certain medicines at the same time as sertraline. Your doctor may wish to stop your treatment.

-    If you develop yellow skin and eyes which may mean liver damage.

-    If you experience depressive symptoms with ideas of harming or killing yourself (suicidal thoughts).

-    If you start to get feelings of restlessness and are not able to sit or stand still after you start to take Besitran.

You should tell your doctor if you start to feel restless.

-    If you have a fit (seizure).

-    If you have a manic episode (see section 2 “Take special care with Besitran”).

The following side effects were seen in clinical trials in adults.

Very common side effects (occurs in more than 1 out of 10 patients):

Insomnia, dizziness, sleepiness, headache, diarrhoea, feeling sick, dry mouth, ejaculation failure, fatigue.

Common side effects (occurs in between 1 and 10 out of 100 patients):

-    Sore throat, anorexia, increased appetite,

-    depression, feeling strange, nightmare, anxiety, agitation, nervousness, decreased sexual interest, teeth grinding,

-    numbness and tingling, shaking, muscle tense, abnormal taste, lack of attention,

-    visual disturbance, ringing in ears,

-    palpitations, hot flush, yawning,

-    abdominal pain, vomiting, constipation, upset stomach, gas,

-    rash, increased sweating, muscle pain, sexual dysfunction, erectile dysfunction, chest pain.

-    joint pain,

-    Malaise.

Uncommon side effects (occurs in between 1 and 10 out of 1.000 patients):

-    Chest cold, runny nose,

-    hypersensitivity,

-    low thyroid hormones,

-    hallucination, feeling too happy, lack of caring, thinking abnormal, aggression,

-    convulsion, involuntary muscle contractions, abnormal coordination, moving a lot, amnesia, decreased feeling, speech disorder, dizziness while standing up, passing out, migraine,

-    enlarged pupils,

-    ear pain, fast heartbeat, high blood pressure, flushing,

-    breathing difficulty, possible wheezing, shortness of breath, nose bleed,

-    inflammation of the oesophagus, difficulty swallowing, haemorrhoids, increased saliva, tongue disorder, burping,

-    eye swelling, purple spots on skin, face oedema, hair loss, cold sweat, dry skin, hives, itching,

-    osteoarthritis, muscular weakness, back pain, muscle twitching,

-    nighttime urination, unable to urinate, increase in urination, increase in frequency of urination, problem urinating, urinary incontinence,

-    vaginal haemorrhage, sexual dysfunction, female sexual dysfunction, menstrual irregularities, swelling in legs, chills, fever, weakness, thirst, increase in liver enzyme levels, weight decreased, weight increased.

Rare side effects (occurs in between 1 and 10 out of 10.000 patients):

-    Intestine problem, ear infection, cancer, swollen glands, high cholesterol, low blood sugar,

-    physical symptoms due to stress or emotions, drug dependence, psychotic disorder, paranoia, suicidal thoughts, sleep walking, premature ejaculation,

-    severe allergic reaction,

-    coma, abnormal movements, difficulty moving, increased sensation, sensory disturbance,

-    glaucoma, tear problem, spots in front of eyes, double vision, light hurts eye, blood in the eye,

-    problems controlling blood sugar levels (diabetes),

-    heart attack, slow heart beat, heart problem, poor circulation of arms and legs, closing up of throat, breathing fast, breathing slow, difficulty talking, hiccups,

-    blood in stool, sore mouth, tongue ulceration, tooth disorder, tongue problem, mouth ulceration, problems with liver function,

-    skin problem with blisters, hair rash, hair texture abnormal, skin odour abnormal, bone disorder,

-    decreased urination, urinary hesitation, blood in urine,

-    excessive vaginal bleeding, dry vaginal area, red painful penis and foreskin, genital discharge, prolonged erection, breast discharge,

-    hernia, drug tolerance decreased, difficulty walking, semen abnormal, increase in blood cholesterol levels, injury, relaxation of blood vessels procedure.

-    Cases of suicidal ideation and suicidal behaviours have been reported during sertraline therapy or early after treatment discontinuation (see section 2.).

After marketing sertraline, the following side effects have been reported:

-    Decrease in white blood cells, decrease in clotting cells, endocrine problem, low blood salt, increase in blood sugar levels,

-    terrifying abnormal dreams, suicidal behaviour,

-    muscular movement problems (such as moving a lot, tense muscles, difficulty walking and stiffness, spasms and involuntary movements of the muscles), sudden severe headache (which may be a sign of a serious condition known as Reversible Cerebral Vasoconstriction Syndrome (RCVS)),

-    vision abnormal, unequal sized pupils, bleeding problems (such as stomach bleeding), progressive scarring of lung tissue (Interstitial Lung Disease), pancreatitis, serious liver function problems, yellow skin and eyes (jaundice),

-    skin oedema, skin reaction to sun, muscle cramps, breast enlargement, problems with clotting, bedwetting.

Side effects in children and adolescents

In clinical trials with children and adolescents, the side effects were generally similar to adults (see above). The most common side effects in children and adolescents were headache, insomnia, diarrhoea and feeling sick.

Symptoms that can occur when treatment is discontinued

If you suddenly stop taking this medicine you may experience side effects such as dizziness, numbness, sleep disturbances, agitation or anxiety, headaches, feeling sick, being sick and shaking (see section 3. “If you stop taking Besitran”).

An increased risk of bone fractures has been observed in patients taking this type of medicines.

Reporting of side effects

If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any possible side effects not listed in this leaflet. You can also report side effects directly via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.

By reporting side effects, you can help provide more information on the safety of this medicine.

5. How to store Besitran

Keep out of the sight and reach of children.

Store below 30oC.

Do not use Besitran after the expiry date which is stated on the pack. The expiry date refers to the last day of that month.

Medicines should not be disposed of via wastewater or household waste. Ask your pharmacist how to dispose of medicines no longer required. These measures will help to protect the environment.

6. Further information What Besitran contains

The active substance is sertraline hydrochloride.

Besitran 50mg Tablets contains 50mg of sertraline (as hydrochloride) Besitran 100mg Tablets contains 100mg of sertraline (as hydrochloride)

Other ingredients: calcium hydrogen phosphate, hydroxypropylcellulose, hydroxypropylmethylcellulose, magnesium stearate, microcrystalline cellulose, polyethylene glycol, polysorbate-80, sodium starch glycollate, and titanium dioxide.

What Besitran looks like and contents of the pack

Besitran 50 mg Tablets are white capsular shaped with the markings “ZLT” AND “50” on one side and “Pfizer” on the other side.

Besitran 100 mg Tablets are white capsular shaped with the markings “ZLT” AND “100” on one side and “Pfizer” on the other side.

Each pack contains 30 tablets.

Manufacturer and Product Licence Holder

Manufactured by Farmasierra Manufacturing S.L., San Sebastian de los Reyes, Madrid, Spain. Procured from within the EU and Repackaged by the Product Licence holder P.I.E. Pharma Ltd, 207 Kenton Road, Harrow, Middlesex HA3 0HD.

POM

Besitran 50 mg Tablets/ Sertraline 50 mg Tablets PL 15361/0043

Besitran 100 mg Tablets/ Sertraline 100 mg Tablets PL 15361/0044

Leaflet issue and revision date (Ref.) 30.05.14[25] Besitran is a trademark of Pfizer Products lnc.