Document: spc-doc_PL 25821-0003 change

• spc-doc_PL 06809-0083
• spc-doc_PL 20416-0037
• spc-doc_PL 25821-0003

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SUMMARY OF PRODUCT CHARACTERISTICS

1 NAME OF THE MEDICINAL PRODUCT

Chlordiazepoxide Capsules BP 5mg

2 QUALITATIVE AND QUANTITATIVE COMPOSITION

Each 5mg capsule contains 5mg of the active ingredient Chlordiazepoxide Hydrochloride

For the full list of excipients, see section 6.1.

Each 10mg capsule contains 10mg of the active ingredient Chlordiazepoxide Hydrochloride

For the full list of excipients, see section 6.1.

3    PHARMACEUTICAL FORM

Capsule.

Yellow/green hard gelatin capsule, overprinted (a) Rima 5 or (b) RCDP 5.

4    CLINICAL PARTICULARS

4.1    Therapeutic indications

Short-term (2-4 weeks) symptomatic treatment of anxiety that is severe, disabling or subjecting the individual to unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic or psychotic illness.

Muscle spasm of varied aetiology.

Symptomatic relief of acute alcohol withdrawal.

4.2    Posology and method of administration

Posology

Anxiety states:

Usual dose, 10mg, 2-3 times a day and up to 30 mg daily in divided doses.

For severe symptoms 20mg, 2-4 times a day. Maximum dose up to 100 mg daily in divided doses, adjusted on an individual basis. Generally, duration of treatment should not be more than 4 weeks, including a tapering-off process.

Insomnia associated with anxiety:

10 to 30 mg before retiring. Generally, duration of treatment varies from a few days to two weeks, with a maximum including a tapering off process of four weeks.

Symptomatic relief of acute alcohol withdrawal: 25 to 100 mg repeated if necessary in 2 to 4 hours.

Muscle spasm of varied aetiology: 10 to 30 mg daily in divided doses. Paediatric patients

This product is not for paediatric use.

Special patient groups

Elderly and debilitated patients, patients with organic brain damage, respiratory impairment and/or hepatic or renal dysfunction should normally not exceed half of the doses normally recommended

The lowest dose which can control symptoms should be used. The dosage and duration of treatment should be determined on an individual basis dependent by the patient’s response and severity of the disorder. Given that chlordiazepoxide is a long-acting benzodiazepine, the patient should be monitored regularly at the start of the treatment to decrease, if necessary, the dose or frequency of administration to prevent overdose due to accumulation.

Treatment should be as short as possible. The patient should be reassessed regularly and the need for continued treatment should be evaluated, especially in case the patient is symptom free.

Treatment should always be tapered off gradually. Patients who have taken benzodiazepines for a prolonged time may require a longer period during which doses are reduced. Specialist help may be appropriate.

Method of administration: Chlordiazepoxide Capsules are for oral administration and must be taken with water and not be chewed.

4.3 Contraindications

Chlordiazepoxide is contraindicated for patients with:

-    Sensitivity to benzodiazepines or to any of the excipients listed in section 6.1

-    Myasthenia gravis

-    Severe pulmonary insufficiency

-    Respiratory depression

-    Severe hepatic insufficiency

-    Sleep apnoea syndrome

-    Phobic or obsessional states Chronic psychosis

4.4 Special warnings and precautions for use

Tolerance

Some loss of efficacy to the hypnotic effects of benzodiazepines may develop after repeated use for a few weeks.

Dependence and withdrawal

The dependent potential of the benzodiazepines is low, particularly when limited to short-term use. Risk for physical and psychological dependence increases when high doses are used, especially when given over long periods. This is particularly so in patients with a history of alcoholism or drug abuse or in patients with marked personality disorders. Regular monitoring in such patients is essential. Routine repeat prescriptions should be avoided and treatment should be withdrawn gradually.

Symptoms such as headaches, muscle pain, extreme anxiety, restlessness, confusion, depression, nervousness, rebound insomnia, irritability, sweating and diarrhoea have been reported following abrupt cessation of treatment in patients receiving even normal therapeutic doses for short periods of time. In severe cases, the following symptoms may occur: derealisation, depersonalisation, hyperacusis, numbness and tingling of the extremities, hypersensitivity to light, noise and physical contact, hallucinations, psychotic manifestations or epileptic seizures.

Rebound insomnia and anxiety: This is a transient syndrome whereby the symptoms that led to treatment with a benzodiazepine recur in an enhanced form, may occur on withdrawal of treatment. It may be accompanied by other reactions including mood changes, anxiety or sleep disturbances and restlessness. Since the risk of withdrawal phenomena/rebound phenomena is greater after abrupt discontinuation of treatment, it is recommended that the dosage is decreased gradually.

Duration of Treatment

The duration of treatment should be as short as possible (see posology) depending on the indication, but should not exceed 4 weeks, including tapering off process. Routine repeat prescriptions should be avoided.

It may be useful to inform the patient when treatment is started that it will be of limited duration and to explain precisely how the dosage will be progressively decreased. Moreover, it is important that the patient should be aware of the possibility of rebound phenomena, thereby minimising anxiety over such symptoms should they occur while the medicinal product is being discontinued.

• When benzodiazepines with a long duration of action are being used, it is important to warn against changing to a benzodiazepine with a short duration of action, as withdrawal symptoms may develop.

Amnesia

Amnesia may occur. Benzodiazepines may induce anterograde amnesia. The condition occurs most often several hours after ingesting the product and therefore, to reduce the risk, patients should ensure that they will be able to have an uninterrupted sleep of 7-8 hours (see also Undesirable Effects).

Psychiatric and paradoxical reactions:

Rare behavioural effects including restlessness, agitation, irritability, aggressiveness, delusion, rages, nightmares, hallucinations, psychoses, inappropriate behaviour and other adverse behavioural effects are known to occur when using benzodiazepines. Should this occur, use of the medicinal product should be discontinued. They are more likely to occur in children and the elderly.

Specific patient groups:

Elderly patients should be given a reduced dose (see section 4.2). A lower dose is also recommended for patients with chronic respiratory insufficiency due to the risk of respiratory depression. Benzodiazepines are contraindicated to treat patients with severe hepatic insufficiency as they may precipitate encephalopathy and reduced doses should be given to patients with renal or hepatic disease.

Benzodiazepines are not recommended for the primary treatment of psychotic illness.

Chlordiazepoxide should not be used alone to treat depression or anxiety associated with depression, since it may uncover depression with suicidal tendencies. Extreme caution should be used in prescribing benzodiazepines to patients with personality disorders. Benzodiazepines should be used with extreme caution in patients with a history of alcohol or drug abuse.

In cases of loss or bereavement, psychological adjustment may be inhibited by benzodiazepines.

Due to myorelaxant effect there is a risk of falls and consequently fractures in the elderly.

Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take Chlordiazepoxide

4.5 Interaction with other medicinal products and other forms of interaction

If chlordiazepoxide is combined with centrally-acting drugs such as neuroleptics, tranquillisers, antidepressants, hypnotics, analgesics, anaesthetics, or sedative antihistamines the sedative effects are likely to be intensified. In the case of narcotic analgescis, enhancement of the euphoria may also occur leading to an increase in psychic dependence. The elderly require special supervision.

Concomitant intake with alcohol should be avoided. The sedative effect may be enhanced when the product is used in combination with alcohol. This adversely affects the ability to drive or use machines.

When chlordiazepoxide is used in conjunction with antiepileptic drugs, side effects and toxicity may be more evident, particularly with hydantoins or barbiturates or combinations including them. Therefore extra caution is required in adjusting dosage in the initial stages of treatment.

Known inhibitors of hepatic enzymes, e.g. cimetidine, omeprazole and disulfiram have been shown to reduce the clearance of benzodiazepines and may potentiate their action. The same applies to the use of contraceptive agents. Known inducers of hepatic enzymes e.g. rifampicin, may increase the clearance of benzodiazepines.

In patients receiving long-term treatment with other medicines (such as centrally acting antihypertensive agents, beta receptor blockers, anticoagulant agents and cardiac glycosides) nature and extent of interactions cannot safety be foreseen.

Benzodiazepines possibly antagonize the effect of levodopa.

Sedative effects are possibly increased when benzodiazepines are given with moxonidine.

Benzodiazepines enhance effects of sodium oxybate. Concomitant use should be avoided.

Effects of benzodiazepines are possibly reduced by theophylline.

4.6 Fertility, Pregnancy and lactation

Pregnancy

There is no evidence as to drug safety in human pregnancy, nor is there evidence from animal work that it is free from hazard. Do not use during pregnancy, especially during the first and last trimesters, unless there are compelling reasons.

If the product is prescribed to a woman of childbearing potential, she should be warned to contact her physician regarding discontinuance of the product if she intends to become or suspects that she is pregnant.

The administration of high doses or prolonged administration of low doses of benzodiazepines in the last trimester of pregnancy has been reported to produce irregularities in the foetal heart rate, and hypotonia, poor sucking and hypothermia in the neonate.

Moreover, infants born to mothers who took benzodiazepines chronically during the latter stages of pregnancy, may have developed physical dependence and may be at some risk for developing withdrawal symptoms in the postnatal period.

Breast-feeding

Chlordiazepoxide may appear in breast milk. If possible the use of Chlordiazepoxide Capsules should be avoided during breast-feeding.

4.7 Effects on ability to drive and use machines

Patients should be advised that chlordiazepoxide may modify patients' performance at skilled tasks such as driving, operating machinery etc. to a varying degree depending upon dosage, administration and individual susceptibility. Concurrent use of alcohol may potentiate any impairment. Alcohol should therefore be avoided during treatment.

Sedation, amnesia, impaired concentration and impaired muscular function are possible undesirable effects that may affect your ability to drive or operate machinery.

If insufficient sleep duration occurs, the likelihood of impaired alertness may be increased (see also interactions).

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

Common adverse effects include drowsiness, sedation, dizziness, unsteadiness and ataxia; these are dose-related and may persist into the following day even after a single dose. However, these phenomena occur predominantly at the start of the therapy and usually disappear with repeated administration. The elderly are particularly sensitive to the effects of centrally-depressant drugs and may experience the confusion, especially if organic brain changes are present; and the dosage of Chlordiazepoxide should not exceed one-half that recommended for other adults.

Evaluation of undesirable effects is based on the following frequency information; 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 (frequency cannot be estimated from available data)

Blood and lymphatic system disorders:

Rare: Bone marrow depression (e.g. thrombocytopenia, leukopenia, agranulocytosis, pancytopenia)

Immune system disorders:

Very rare: anaphylactic reactions, angioedema Frequency not known: Hypersensitivity

Psychiatric disorders:

Frequency not known: Amnesia, hallucinations, dependence, depression, restlessness, agitation, irritability, depressed level of consciousness, aggression, delusion, nightmares, psychotic disorder, abnormal behavior, emotional disturbances, paradoxical drug reaction (e.g. anxiety, sleep disorders, insomnia, suicide attempt, suicidal ideation).

Nervous system disorders:

Common: Sedation, dizziness, unsteadiness, somnolence, ataxia, balance disorder, confusional states.

Rare: Headache, vertigo

Frequency not known: Dysarthria, gait disturbance, extrapyramidal disorder (e.g. tremor, dyskinesia)

Eye disorders:

Rare: Visual impairment including diplopia Vascular disorders:

Rare: Hypotension

Respiratory, thoracic and mediastinal disorders:

Frequency not known: Respiratory depression.

Gastrointestinal disorders:

Rare: Gastrointestinal upsets Hepatobiliary disorders:

Frequency not known: Jaundice, blood bilirubin increased, transaminases increased, blood alkaline phosphatase increased.

Skin and subcutaneous tissue disorders:

Rare: Skin reaction (e.g. rash)

Musculoskeletal and connective tissue disorders:

Due to the myorelaxant effect there is a risk of falls and consequently fractures in the elderly.

Frequency not known: Muscle weakness Renal and urinary disorders:

Rare: Urinary retention, incontinence Reproductive system and breast disorders:

Rare: Libido disorders, erectile dysfunction, menstrual disorder General disorders and administration site conditions:

Common: Fatigue

Frequency not known: Changes in salivation Amnesia:

Anterograde amnesia may occur using therapeutic doses, with increasing the risk at higher doses. This may be associated with inappropriate behaviour (see section 4.4).

Depression:

Pre-existing depression may be unmasked during benzodiazepine use. Psychiatric and paradoxical reactions:

Reactions like restlessness, agitation, irritability, aggressiveness, delusion, rages, nightmares, hallucinations, psychoses, inappropriate behaviour and other adverse behavioural effects are known to occur when using benzodiazepine-like agents. They may be quite severe with this product.

They are more likely to occur in the elderly.

Dependence:

Use (even at therapeutic doses) may lead to the development of physical dependence: discontinuation of the therapy may result in the withdrawal or rebound phenomena. Psychological dependence may occur. Abuse of benzodiazepines has been reported.

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

When taken alone in overdosage, Chlordiazepoxide presents few problems in management. When taken with centrally-acting drugs, especially alcohol, the effects of overdose are likely to be more severe and in the absence of supportive measures may prove fatal.

Symptoms:

Overdose of benzodiazepines is usually manifested by degrees of central nervous system depression ranging from drowsiness to coma. In mild cases, symptoms include drowsiness, mental confusion and lethargy, in more serious cases, symptoms may include ataxia, hypotonia, hypotension, respiratory depression, rarely coma and very rarely death.

Management:

In the management of overdose with any medicinal product, it should be borne in mind that multiple agents may have been taken.

Treatment is symptomatic. The benefit of gastric decontamination is uncertain. Consider activated charcoal (charcoal dose: 50g for an adult, 1g/kg for a child) in adults or children who have taken more than a potentially toxic amount within 1 hour, provided the airway can be protected.

The value of dialysis has not been determined. Flumazenil, a benzodiazepine antagonist, is available but should rarely be required. It may be required in children who are naive to benzodiazepines or patients with COPD as an alternative to ventilation. Flumazenil has a short half-life (about an hour) and in this situation an infusion may therefore be required. Flumazenil should not normally be used in patients with a history of seizures, head injury, chronic benzodiazepine use, co-ingestion of a benzodiazepine and tricyclic antidepressant or other proconvulsant.

If excitation occurs, bartiturates should not be used.

5 PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Psycholeptica, anxiolytics, benzodiazepine derivatives.

ATC code: NO5 BA02

Chlordiazepoxide is a psychotropic substance from the class of 1,4-benzodiazepines with tension, excitement, anxiety attenuating properties and sedative and hypnotic effects. Chlordiazepoxide shows muscle relaxant and anticonvulsant effects.

Chlordiazepoxide has a low affinity as an agonist at specific benzodiazepine receptors located on GABA-ergic neurons. Stimulation of benzodiazepine receptors potentates the actions of GABA. GABA-ergic neurons are inhibitory in the nervous system.

This results in diminution of various 5-HT, dopamine and noradrenergic neurotransmitter system effects.

5.2 Pharmacokinetic properties

Absorption:

Chlordiazepoxide is well absorbed, with peak blood levels being achieved one or two hours after administration.

Steady-state levels are usually reached within three days.

Distribution:

Chlordiazepoxide is metabolised to desmethyl-chlordiazepoxide. Demoxepam and desmethyldiazepam are also found in the plasma of patients on continuous treatment. The active metabolite desmethyl-chlordiazepoxide has an accumulation half-life of 10-18 hours; that of demoxepam has been reached as 21-78 hours.

Steady-state levels of these active metabolites are reached after 10-15 days, with metabolite concentrations which are similar to those of the parent drug.

Elimination:

The drug has a half-life of 6-30 hours.

Pharmacokinetic/pharmacodynamics relationship:

No clear correlation has been demonstrated between the blood levels of Chlordiazepoxide and its clinical effects.

5.3 Preclinical safety data

There are no pre-clinical data of relevance to the prescriber which are additional to that already included in other sections of the SPC.

6    PHARMACEUTICAL PARTICULARS

6.1    List of excipients

Lactose Monohydrate 110#

Maize Starch Magnesium Stearate

Capsule shell components:

Body:

Erythrosine (E127)

Quinoline Yellow (E104)

Titanium Dioxide (E171)

Gelatin

Cap:

Quinoline Yellow (E104)

Indigotine (E132)

Titanium Dioxide (E171)

Gelatin

6.2    Incompatibilities

Not applicable

6.3 Shelf life

12 months