Document: spc-doc_PL 08553-0173 change

• spc-doc_PL 00289-0493
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• spc-doc_PL 04569-0512
• spc-doc_PL 08553-0173
• spc-doc_PL 11311-0412
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SUMMARY OF PRODUCT CHARACTERISTICS

1    NAME OF THE MEDICINAL PRODUCT

Ciprofloxacin 250 mg film-coated tablets

2    QUALITATIVE AND QUANTITATIVE COMPOSITION

Ciprofloxacin 250.00 mg (as ciprofloxacin hydrochloride).

For the full list of excipients, see section 6.1

3    PHARMACEUTICAL FORM

Film-coated tablets.

White, oval shaped film-coated tablets debossed ‘C250’ on one side and breakline on other side.

4    CLINICAL PARTICULARS

4.1    Therapeutic indications

Ciprofloxacin film-coated tablets are indicated for the treatment of the following infections (see sections 4.4 and 5.1). Special attention should be paid to available information on resistance to ciprofloxacin before commencing therapy.

Consideration should be given to official guidance on the appropriate use of antibacterial agents.

Adults

•    Lower respiratory tract infections due to Gram-negative bacteria

-    exacerbations of chronic obstructive pulmonary disease

-    broncho-pulmonary infections in cystic fibrosis or in bronchiectasis

-    pneumonia

•    Chronic suppurative otitis media

•    Acute exacerbation of chronic sinusitis especially if these are caused by Gram-negative bacteria

•    Urinary tract infections

•    Genital tract infections

•    gonococcal uretritis and cervicitis due to susceptible Neisseria gonorrhoeae

•    epididymo-orchitis including cases due to Neisseria gonorrhoeae

•    pelvic inflammatory disease including infections due to Neisseria gonorrhoeae

•    Infections of the gastro-intestinal tract (e.g. travellers’ diarrhoea)

•    Intra-abdominal infections

•    Infections of the skin and soft tissue caused by Gram-negative bacteria

•    Malignant external otitis

•    Infections of the bones and joints

•    Prophylaxis of invasive infections due to Neisseria meningitidis

•    Inhalation anthrax (post-exposure prophylaxis and curative treatment)

Ciprofloxacin may be used in the management of neutropenic patients with fever that is suspected to be due to a bacterial infection.

Children and adolescents

•    Broncho-pulmonary infections in cystic fibrosis caused by Pseudomonas aeruginosa

•    Complicated urinary tract infections and pyelonephritis

•    Inhalation anthrax (post-exposure prophylaxis and curative treatment)

Ciprofloxacin may also be used to treat severe infections in children and adolescents when this is considered to be necessary.

Treatment should be initiated only by physicians who are experienced in the treatment of cystic fibrosis and/or severe infections in children and adolescents (see sections 4.4 and 5.1).

4.2 Posology and method of administration

Posology

The dosage is determined by the indication the severity and the site of infection, the susceptibility to ciprofloxacin of the causative organism(s), the renal function of the patient and, in children and adolescents the body weight. The duration of treatment depends on the severity of the illness and on the clinical and bacteriological course

Treatment of infections due to certain bacteria (e.g. Pseudomonas aeruginosa, Acinetobacter or Staphylococci) may require higher ciprofloxacin doses and co-administration with other appropriate antibacterial agents.

Treatment of some infections (e.g. pelvic inflammatory disease, intraabdominal infections, infections in neutropenic patients and infections of bones and joints) may require co-administration with other appropriate antibacterial agents depending on the pathogens involved.

Adults

Indications		Daily dose in mg	Total duration of treatment (potentially including initial parenteral treatment with ciprofloxacin)
Infections of the lower respiratory tract		500mg twice daily to 750mg twice daily	7 to 14 days
Infections of the upper respiratory tract	Acute exacerbation of chronic sinusitis	500mg twice daily to 750mg twice daily	7 to 14 days

	Chronic suppurative otitis media	500mg twice daily to 750mg twice daily	7 to 14 days
	Malignant external otitis	750mg twice daily	28 days up to 3 months
Urinary tract infections	Uncomplicated cystitis	250mg twice daily to 500mg twice daily	3 days
(see section 4.4)		In pre-menopausal women, 500mg single dose may be used
	Complicated cystitis, Uncomplicated pyelonephritis	500mg twice daily	7 days
	Complicated pyelonephritis	500mg twice daily to 750mg twice daily	at least 10 days, it can be continued for longer than 21 days in some specific circumstances (such as abscesses)
	Prostatitis	500mg twice daily to 750mg twice daily	2 to 4 weeks (acute) to 4 to 6 weeks (chronic)
Genital tract infections	Gonococcal uretritis and cervicitis	500mg as a single dose	1 day (single dose)
	Epididymo-orchitis and pelvic inflammatory diseases	500mg twice daily to 750mg twice daily	at least 14 days
Infections of the gastro-intestinal tract and intra-abdominal infections	Diarrhoea caused by bacterial pathogens including Shigella spp. other than Shigella dysenteriae type 1 and empirical treatment of severe travellers’ diarrhoea	500mg twice daily	1 day
	Diarrhoea caused by Shigella dysenteriae type 1	500mg twice daily	5 days
	Diarrhoea caused by Vibrio cholerae	500mg twice daily	3 days
	Typhoid fever	500mg twice daily	7 days
	Intra-abdominal infections due to Gramnegative bacteria	500mg twice daily to 750mg twice daily	5 to 14 days
Infections of the skin and soft tissue		500mg twice daily to 750mg twice daily	7 to 14 days
Bone and joint infections		500mg twice daily to 750mg twice daily	max. of 3 months
Neutropenic patients with fever that is		500mg twice daily to	Therapy should be continued

suspected to be due to a bacterial infection. Ciprofloxacin should be co-administered with appropriate antibacterial agent(s) in accordance to official guidance.	750mg twice daily	over the entire period of neutropenia
Prophylaxis of invasive infections due to Neisseria meningitidis	500mg as a single dose	1 day (single dose)
Inhalation anthrax post-exposure prophylaxis and curative treatment for persons able to receive treatment by oral route when clinically appropriate. Drug administration should begin as soon as possible after suspected or confirmed exposure.	500mg twice daily	60 days from the confirmation of Bacillus anthracis exposure

Paediatric _ population

Indications	Daily dose in mg	Total duration of treatment (potentially including initial parenteral treatment with ciprofloxacin)
Cystic fibrosis	20mg/kg body weight twice daily with a maximum of 750mg per dose.	10 to 14 days
Complicated urinary tract infections and pyelonephritis	10mg/kg body weight twice daily to 20mg/kg body weight twice daily with a maximum of 750mg per dose.	10 to 21 days
Inhalation anthrax post-exposure prophylaxis and curative treatment for persons able to receive treatment by oral route when clinically appropriate. Drug administration should begin as soon as possible after suspected or confirmed exposure.	10mg/kg body weight twice daily to 15mg/kg body weight twice daily with a maximum of 500mg per dose.	60 days from the confirmation of Bacillus anthracis exposure
Other severe infections	20mg/kg body weight twice daily with a maximum of 750mg per dose.	According to the type of infections

Elderly _ patients

Elderly patients should receive a dose selected according to the severity of the infection and the patient’s creatinine clearance.

Patients with renal and hepatic impairment

Recommended starting and maintenance doses for patients with impaired renal function:

Creatinine Clearance [mL/min/1.73 m2]	Serum Creatinine [pmol/L]	Oral Dose [mg]
> 60	< 124	See Usual Dosage.
30-60	124 to 168	250-500mg every 12 h
< 30	> 169	250-500mg every 24 h
Patients on haemodialysis	> 169	250-500mg every 24 h (after dialysis)
Patients on peritoneal dialysis	> 169	250-500mg every 24 h

In patients with impaired liver function no dose adjustment is required.

Dosing in children with impaired renal and/or hepatic function has not been studied.

Method of administration

Tablets are to be swallowed unchewed with fluid. They can be taken independent of mealtimes. If taken on an empty stomach, the active substance is absorbed more rapidly. Ciprofloxacin tablets should not be taken with dairy products (e.g. milk, yoghurt) or mineral-fortified fruit-juice (e.g. calcium-fortified orange juice) (see section 4.5).

In severe cases or if the patient is unable to take tablets (e.g. patients on enteral nutrition), it is recommended to commence therapy with intravenous ciprofloxacin until a switch to oral administration is possible.

4.3 Contraindications

•    Hypersensitivity to the active substance, to other quinolones or to any of the excipients listed in section 6.1.

•    Concomitant administration of ciprofloxacin and tizanidine (see section 4.5).

4.4 Special warnings and precautions for use

Severe infections and mixed infections with Gram-positive and anaerobic pathogens

Ciprofloxacin monotherapy is not suited for treatment of severe infections and infections that might be due to Gram-positive or anaerobic pathogens. In such infections ciprofloxacin must be co-administered with other appropriate antibacterial agents.

Streptococcal Infections (including Streptococcus pneumonia)

Ciprofloxacin is not recommended for the treatment of streptococcal infections due to inadequate efficacy.

Genital tract infections

Gonococcal uretritis, cervicitis, epididymo-orchitis and pelvic inflammatory disease may be caused by fluoroquinolone-resistant Neisseria gonorrhoeae isolates.

Therefore, ciprofloxacin should be administered for the treatment of gonococcal uretritis or cervicitis only if ciprofloxacin-resistant Neisseria gonorrhoeae can be excluded.

For epididymo-orchitis and pelvic inflammatory diseases, empirical ciprofloxacin should only be considered in combination with another appropriate antibacterial agent (e.g. a cephalosporin) unless ciprofloxacin-resistant Neisseria gonorrhoeae can be excluded. If clinical improvement is not achieved after 3 days of treatment, the therapy should be reconsidered.

Urinary tract infections

Resistance to fluoroquinolones of Escherichia coli- the most common pathogen involved in urinary tract infections - varies across the European Union. Prescribers are advised to take into account the local prevalence of resistance in Escherichia coli to fluoroquinolones.

The single dose of ciprofloxacin that may be used in uncomplicated cystitis in pre-menopausal women is expected to be associated with lower efficacy than the longer treatment duration. This is all the more to be taken into account as regards the increasing resistance level of Escherichia coli to quinolones.

Intra-abdominal infections

There are limited data on the efficacy of ciprofloxacin in the treatment of postsurgical intra-abdominal infections.

Travellers’ diarrhoea

The choice of ciprofloxacin should take into account information on resistance to ciprofloxacin in relevant pathogens in the countries visited.

Infections of the bones and joints

Ciprofloxacin should be used in combination with other antimicrobial agents depending on the results of the microbiological documentation.

Inhalational anthrax

Use in humans is based on in-vitro susceptibility data and on animal experimental data together with limited human data. Treating physicians should refer to national and/or international consensus documents regarding the treatment of anthrax.

Paediatric population

The use of ciprofloxacin in children and adolescents should follow available official guidance. Ciprofloxacin treatment should be initiated only by physicians who are experienced in the treatment of cystic fibrosis and/or severe infections in children and adolescents.

Ciprofloxacin has been shown to cause arthropathy in weight-bearing joints of immature animals. Safety data from a randomised double-blind study on ciprofloxacin use in children (ciprofloxacin: n = 335, mean age = 6.3 years; comparators: n = 349, mean age = 6.2 years; age range = 1 to 17 years) revealed an incidence of suspected drug-related arthropathy (discerned from joint-related clinical_signs and symptoms) by Day +42 of 7.2% and 4.6%. Respectively, an incidence of drug-related arthropathy by 1-year follow-up

was 9.0% and 5.7%. The increase of suspected drug-related arthropathy cases over time was not statistically significant between groups. Treatment should be initiated only after a careful benefit/risk evaluation, due to possible adverse events related to joints and/or surrounding tissue (see section 4.8).

Broncho-pulmonary infections in cystic fibrosis

Clinical trials have included children and adolescents aged 5-17 years. More limited experience is available in treating children between 1 and 5 years of age.

Complicated urinary tract infections and pyelonephritis Ciprofloxacin treatment of urinary tract infections should be considered when other treatments cannot be used, and should be based in the results of the microbiological documentation. Clinical trials have included children and adolescents aged 1-17 years.

Other specific severe infections

Other severe infections in accordance with official guidelines, or after careful benefit-risk evaluation when other treatments cannot be used, or after failure to conventional therapy and when the microbiological documentation can justify a ciprofloxacin use.

The use of ciprofloxacin for specific severe infections other than those mentioned above has not been evaluated in clinical trials and the clinical experience is limited. Consequently, caution is advised when treating patients with these infections.

Hypersensitivity

Hypersensitivity and allergic reactions, including anaphylaxis and anaphylactoid reactions, may occur following a single dose (see section 4.8) and may be life-threatening. If such reaction occurs, ciprofloxacin should be discontinued and an adequate medical treatment is required.

Musculoskeletal System

Ciprofloxacin should generally not be used in patients with a history of tendon disease/disorder related to quinolone treatment. Nevertheless, in very rare instances, after microbiological documentation of the causative organism and evaluation of the risk/benefit balance, ciprofloxacin may be prescribed to these patients for the treatment of certain severe infections, particularly in the event of failure of the standard therapy or bacterial resistance, where microbiological data may justify the use of ciprofloxacin.

Tendinitis and tendon rupture (especially Achilles tendon), sometimes bilateral, may occur with ciprofloxacin, as soon as the first 48 hours of treatment. Inflammation and ruptures of tendon may occur even up to several months after discontinuation of ciprofloxacin therapy. The risk of tendinopathy may be increased in elderly patients or in patients concomitantly treated with corticosteroids (see section 4.8).

At any sign of tendinitis (e.g. painful swelling, inflammation), ciprofloxacin treatment should be discontinued. Care should be taken to keep the affected limb at rest.

Ciprofloxacin should be used with caution in patients with myasthenia gravis because symptoms can be exacerbated (see section 4.8).

Photosensitivity

Ciprofloxacin has been shown to cause photosensitivity reactions. Patients taking ciprofloxacin should be advised to avoid direct exposure to either extensive sunlight or UV irradiation during treatment (see section 4.8).

Central Nervous System

Ciprofloxacin like other quinolones are known to trigger seizures or lower the seizure threshold. Cases of status epilepticus have been reported. Ciprofloxacin should be used with caution in patients with CNS disorders which may be predisposed to seizure. If seizures occur ciprofloxacin should be discontinued (see section 4.8). Psychiatric reactions may occur even after the first administration of ciprofloxacin. In rare cases, depression or psychosis can progress to suicidal ideations/thoughts culminating in attempted suicide or completed suicide. In the occurrence of such cases, ciprofloxacin should be discontinued.

Cases of polyneuropathy (based on neurological symptoms such as pain, burning, sensory disturbances or muscle weakness, alone or in combination) have been reported in patients receiving ciprofloxacin. Ciprofloxacin should be discontinued in patients experiencing symptoms of neuropathy, including pain, burning, tingling, numbness and/or weakness in order to prevent the development of an irreversible condition (see section 4.8).

Cardiac disorders

Caution should be taken when using fluoroquinolones including ciprofloxacin, in patients with known risk factors for prolongation of the QT interval such as, for example:

•    congenital long QT syndrome

•    concomitant use of drugs that are known to prolong the QT interval (e.g. Class IA and III anti-arrhythmics, tricyclic antidepressants, macrolides, antipsychotics)

•    uncorrected electrolyte imbalance (e.g. hypokalaemia, hypomagnesaemia)

•    cardiac disease (e.g. heart failure, myocardial infarction, bradycardia)

Elderly patients and women may be more sensitive to QTc-prolonging medications. Therefore caution should be taken when using fluoroquinolones, including ciprofloxacin, in these populations.

(See section 4.2 Elderly patients, section 4.5, section 4.8 and section 4.9). Hypoglycaemia

As with other quinolones, hypoglycaemia has been reported most often in diabetic patients, predominantly in the elderly population. In all diabetic patients, careful monitoring of blood glucose is recommended (see section 4.8).

Gastrointestinal System

The occurrence of severe and persistent diarrhoea during or after treatment (including several weeks after treatment) may indicate an antibiotic-associated colitis (life-threatening with possible fatal outcome), requiring immediate treatment (see section 4.8). In such cases, ciprofloxacin should immediately be discontinued, and an appropriate therapy initiated. Anti-peristaltic drugs are contraindicated in this situation.

Renal and urinary system

Crystalluria related to the use of ciprofloxacin has been reported (see section 4.8). Patients receiving ciprofloxacin should be well hydrated and excessive alkalinity of the urine should be avoided.

Impaired renal function

Since ciprofloxacin is largely excreted unchanged via renal pathway dose adjustment is needed in patients with impaired renal function as described in section 4.2 to avoid an increase in adverse drug reactions due to accumulation of ciprofloxacin.

Hepatobiliary system

Cases of hepatic necrosis and life-threatening hepatic failure have been reported with ciprofloxacin (see section 4.8). In the event of any signs and symptoms of hepatic disease (such as anorexia, jaundice, dark urine, pruritus or tender abdomen), treatment should be discontinued.

Glucose-6-phosphate dehydrogenase deficiency

Haemolytic reactions have been reported with ciprofloxacin in patients with glucose-6-phosphate dehydrogenase deficiency. Ciprofloxacin should be avoided in these patients unless the potential benefit is considered to outweigh the possible risk. In this case, potential occurrence of haemolysis should be monitored.

Resistance

During or following a course of treatment with ciprofloxacin bacteria that demonstrate resistance to ciprofloxacin may be isolated, with or without a clinically apparent superinfection. There may be a particular risk of selecting for ciprofloxacin-resistant bacteria during extended durations of treatment and when treating nosocomial infections and/or infections caused by Staphylococcus and Pseudominas species.

Cytochrome P450

Ciprofloxacin inhibits CYP1A2 and thus may cause increased serum concentration of concomitantly administered substances metabolized by this enzyme (e.g. theophylline, clozapine, olanzapine, ropinirole, tizanidine, duloxetine, agomelatine). Co-administration of ciprofloxacin and tizanidine is contra-indicated. Therefore patients taking these substances concomitantly with ciprofloxacin should be monitored closely for clinical signs of overdose, and determination of serum concentrations (e.g. of theophylline) may be necessary (see section 4.5).

Methotrexate

The concomitant use of ciprofloxacin with methotrexate is not recommended (see section 4.5).

Interaction with tests

The in-vitro activity of ciprofloxacin against Mycobacterium tuberculosis might give false negative bacteriological test results in specimens from patients currently taking ciprofloxacin.

Vision disorders

If vision becomes impaired or any effects on the eyes are experienced, an eye specialist should be consulted immediately.

4.5 Interaction with other medicinal products and other forms of interaction

Effects of other products on ciprofloxacin Drugs known to prolong QT interval

Ciprofloxacin like other fluoroquinolones should be used with caution in patients receiving drugs known to prolong QT interval (e.g. Class IA or III antiarrhythmics, tricyclic antidepressants, macrolides, antipsychotics) (see section 4.4).

Chelation Complex Formation

The simultaneous administration of ciprofloxacin (oral) and multivalent cation-containing drugs and mineral supplements (e.g. calcium, magnesium, aluminium, iron), polymeric phosphate binders (e.g. sevelamer or lanthanum carbonate), sucralfate or antacids, and highly buffered drugs (e.g. didanosine tablets) containing magnesium, aluminium or calcium reduces the absorption of ciprofloxacin. Consequently, ciprofloxacin should be administered either 1 - 2 hours before or at least 4 hours after the preparation.

The restriction does not apply to antacids belonging to the class of H2 receptor blockers.

Food and Dairy Products

Dietary calcium as part of a meal does not significantly affect absorption. However, the concurrent administration of dairy products or mineral-fortified drinks alone (e.g. milk, yoghurt, calcium-fortified orange juice) with ciprofloxacin should be avoided because absorption of ciprofloxacin may be reduced.

Probenecid

Probenecid interferes with renal secretion of ciprofloxacin. Co-administration of probenecid and ciprofloxacin increases ciprofloxacin serum concentrations.

Metoclopramide

Metoclopramide accelerates the absorption of ciprofloxacin (oral) resulting in a shorter time to reach maximum plasma concentrations. No effect was seen on the bioavailability of ciprofloxacin.

Omeprazole

Concomitant administration of ciprofloxacin and omeprazole containing medicinal products results in a slight reduction of C_max and AUC of ciprofloxacin.

Effects of ciprofloxacin on other medicinal products:

Tizanidine

Tizanidine must not be administered together with ciprofloxacin (see section 4.3). In a clinical study with healthy subjects, there was an increase in serum tizanidine concentration (C_max increase: 7-fold, range: 4 to 21-fold; AUC increase: 10-fold, range: 6 to 24-fold) when given concomitantly with ciprofloxacin. Increased serum tizanidine concentration is associated with a potentiated hypotensive and sedative effect.

Methotrexate

Renal tubular transport of methotrexate may be inhibited by concomitant administration of ciprofloxacin, potentially leading to increased plasma levels of methotrexate and increased risk of methotrexate-associated toxic reactions. The concomitant use is not recommended (see section 4.4).

Theophylline

Concurrent administration of ciprofloxacin and theophylline can cause an undesirable increase in serum theophylline concentration. This can lead to theophylline-induced side effects that may rarely be life threatening or fatal. During the combination, serum theophylline concentrations should be checked and the theophylline dose reduced as necessary (see section 4.4).

Other xanthine derivatives

On concurrent administration of ciprofloxacin and caffeine or pentoxifylline (oxpentiphylline), raised serum concentrations of these xanthine derivatives were reported.

Phenytoin

Simultaneous administration of ciprofloxacin and phenytoin may result in increased or reduced serum levels of phenytoin such that monitoring of drug levels is recommended.

Cyclosporin

A transient rise in the concentration of serum creatinine was observed when ciprofloxacin and cyclosporin containing medicinal products were administered simultaneously. Therefore, it is frequently (twice a week) necessary to control the serum creatinine concentrations in these patients.

Vitamin K antagonists

Simultaneous administration of ciprofloxacin with a vitamin K antagonist may augment its anti-coagulant effects. The risk may vary with the underlying infection, age and general status of the patient so that the contribution of ciprofloxacin to the increase in INR (international normalized ratio) is difficult to assess. The INR should be monitored frequently during and shortly after coadministration of ciprofloxacin with a vitamin K antagonist (e.g., warfarin, acenocoumarol, phenprocoumon, or fluindione).

Duloxetine

In clinical studies, it was demonstrated that concomitant use of duloxetine with strong inhibitors of the CYP450 1A2 isozyme such as fluvoxamine, may result in an increase of AUC and C_max of duloxetine. Although no clinical data are available on a possible interaction with ciprofloxacin, similar effects can be expected upon concomitant administration (see section 4.4).

Ropinirole

It was shown in a clinical study that concomitant use of ropinirole with ciprofloxacin, a moderate inhibitor of the CYP450 1A2 isozyme, results in an increase of C_max and AUC of ropinirole by 60% and 84%, respectively. Monitoring of ropinirole-related side effects and dose adjustment as appropriate is recommended during and shortly after co-administration with ciprofloxacin (see section 4.4).

Lidocaine

It was demonstrated in healthy subjects that concomitant use of lidocaine containing medicinal products with ciprofloxacin, a moderate inhibitor of CYP450 1A2 isozyme, reduces clearance of intravenous lidocaine by 22%. Although lidocaine treatment was well tolerated, a possible interaction with ciprofloxacin associated with side effects may occur upon concomitant administration.

Clozapine

Following concomitant administration of 250 mg ciprofloxacin with clozapine for 7 days, serum concentrations of clozapine and N-desmethylclozapine were increased by 29% and 31% respectively. Clinical surveillance and appropriate adjustment of clozapine dosage during and shortly after co-administration with ciprofloxacin are advised (see section 4.4).

Sildenafil

Cmax and AUC of sildenafil were increased approximately twofold in healthy subjects after an oral dose of 50 mg given concomitantly with 500 mg ciprofloxacin. Therefore, caution should be used prescribing ciprofloxacin concomitantly with sildenafil taking into consideration the risks and benefits.

Agomelatine

In clinical studies, it was demonstrated that fluvoxamine, as a strong inhibitor of the CYP450 1A2 isoenzyme, markedly inhibits the metabolism of agomelatine resulting in a 60-fold increase of agomelatine exposure. Although no clinical data are available for a possible interaction with ciprofloxacin, a moderate inhibitor of CYP450 1A2, similar effects can be expected upon concomitant administration (‘Cytochrome P450’ in section ‘Special warnings and precautions for use).

Zolpidem

Co-administration of ciprofloxacin may increase blood levels of zolpidem, concurrent use is not recommended.

4.6 Fertility, pregnancy and lactation

Pregnancy

The data that are available on administration of ciprofloxacin to pregnant women indicates no malformative or feto/neonatal toxicity of ciprofloxacin. Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity. In juvenile and prenatal animals exposed to quinolones, effects on immature cartilage have been observed thus, it cannot be excluded that the drug could cause damage to articular cartilage in the human immature organism/foetus (see section 5.3).

As a precautionary measure, it is preferable to avoid the use of ciprofloxacin during pregnancy.

Breast-feeding

Ciprofloxacin is excreted in breast milk. Due to the potential risk of articular damage, ciprofloxacin should not be used during breast-feeding.

4.7 Effects on ability to drive and use machines

Due to its neurological effects, ciprofloxacin may affect reaction time. Thus the ability to drive or to operate machinery may be impaired.

4.8 Undesirable effects

The most commonly reported adverse reactions (ADRs) are nausea and diarrhoea.

ADRs derived from clinical studies and post-marketing surveillance with ciprofloxacin (oral, intravenous and sequential therapy) sorted by categories of frequency are listed below. The frequency analysis takes into account data from both oral and intravenous administration of ciprofloxacin.

System Organ Class	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	Frequency not known (cannot be estimated from available data)
Infections and Infestations		Mycotic superinfections
Blood and Lymphatic System Disorders		Eosinophilia	Leukopenia Anaemia Neutropenia Leukocytosis Thrombocytopenia Thrombocytaemia	Haemolytic anaemia Agranulocytosis Pancytopenia (life threatening) Bone marrow depression (life threatening)
Immune System Disorders			Allergic reaction Allergic oedema/ angiooedema	Anaphylactic reaction Anaphylactic shock (life threatening) (see section 4.4) Serum sicknesslike reaction
Metabolism and Nutrition Disorders		Decreased appetite	Hyperglycaemia Hypoglycaemia (see section 4.4)
Psychiatric disorders		Psychomotor hyperactivity/ agitation	Confusion and disorientation Anxiety reaction Abnormal dreams Depression (potentially culminating in suicidal ideation/ thoughts or suicide attempts and completed suicide) (see section 4.4) Hallucination	Psychotic reactions (potentially culminating in suicidal ideations/ thought or suicide attempts and completed suicide) (see section 4.4)	Mania, hypomania
Nervous System Disorders		Headache Dizziness Sleep disorders	Par- and Dysaesthesia Hypoaesthesia Tremor	Migraine Disturbed coordination	Peripheral neuropathy and polyneuropathy (see section 4.4)

System Organ Class	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	Frequency not known (cannot be estimated from available data)
		Taste disorders	Seizures (including status epliepticus see section 4.4) Vertigo	Gait disturbance Olfactory nerve disorders Intracranial hypertension and psuedotumor cerebri
Eye Disorders			Visual disturbances (e.g. diplopia)	Visual colour distortions
Ear and Labyrinth Disorders			Tinnitus Hearing loss/ Hearing impaired
Cardiac Disorders			Tachycardia		Ventricular arrhythmia and torsades de pointes (reported predominantly in patients with risk factors for QT prolongation) ECG QT prolonged (see sections 4.4 and 4.9)
Vascular Disorders			Vasodilatation Hypotension Syncope	Vasculitis
Respiratory, Thoracic and Mediastinal Disorders			Dyspnoea (including asthmatic condition)
Gastrointestinal Disorders	Nausea Diarrhoea	Vomiting Gastrointestinal and abdominal pains Dyspepsia Flatulence	Antibiotic associated diarrhoea including pseudomembraneous colitis (very rarely with possible fatal outcome) (see section 4.4)	Pancreatitis
Hepatobiliary Disorders		Increase in transaminases Increased bilirubin	Hepatic impairment Cholestatic icterus Hepatitis	Liver necrosis (very rarely progressing to life-threatening hepatic failure) (see section 4.4)
Skin and Subcutaneous		Rash	Photosensitivity reactions	Petechiae	Acute generalised

System Organ Class	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	Frequency not known (cannot be estimated from available data)
Tissue Disorders		Pruritus Urticaria	(see section 4.4)	Erythema multiforme Erythema nodosum Stevens-Johnson syndrome (potentially life threatening) Toxic epidermal necrolysis (potentially life threatening)	exanthematous pustulosis (AGEP), DRESS
Musculoskeletal, Connective Tissue and Bone Disorders		Musculoskeletal pain (e.g. extremity pain, back pain, chest pain) Arthralgia	Myalgia Arthritis Increased muscle tone and cramping	Muscular weakness Tendinitis Tendon rupture (predominantly Achilles tendon) (see section 4.4) Exacerbation of symptoms of myasthenia gravis (see section 4.4)
Renal and Urinary Disorders		Renal impairment	Renal failure Haematuria Crystalluria (see section 4.4) Tubulointerstitial nephritis
General Disorders and Administration Site Conditions		Asthenia Fever	Oedema Sweating (hyperhidrosis)
Investigations		Increase in blood alkaline phosphatase	Increased amylase		International normalised ratio increased (in patients treated with Vitamin K antagonists)

Paediatric patients

The incidence of arthropathy, mentioned above, is referring to data collected in studies with adults. In children, arthropathy is reported to occur commonly (see section 4.4).

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal products 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,

Website: www.mhra.gov.uk/yellowcard

4.9 Overdose

An overdose of 12g has been reported to lead to mild symptoms of toxicity. An acute overdose of 16g has been reported to cause acute renal failure.

Symptoms of overdose may include dizziness, tremor, headaches, tiredness, seizures, hallucinations, confusion, abdominal discomfort, renal and hepatic impairment as well as crystalluria and haematuria. Reversible renal toxicity has been reported.

Apart from routine emergency measures e.g. ventricular emptying followed by medical carbon, it is recommended to monitor renal function, including urinary pH and acidify, if required, to prevent crystalluria. Patients should be kept well hydrated.

Calcium or magnesium containing antacids may theoretically reduce the absorption of ciprofloxacin in overdoses.

Only a small quantity of ciprofloxacin (<10%) is eliminated by haemodialysis or peritoneal dialysis.

In the event of overdose, symptomatic treatment should be implemented. ECG monitoring should be undertaken, because of the possibility of QT interval prolongation.

5    PHARMACOLOGICAL PROPERTIES

5.1    Pharmacodynamic properties

Pharmacotherapeutic group: Fluoroquinolones ATC code J01M A02

Mechanism of Action:

As a fluoroquinolones antibacterial agent, the bactericidal action of ciprofloxacin results from the inhibition of both type II topoisomerase (DNA-gyrase) and topoisomerase IV, required for bacterial DNA replication, transcription, repair and recombination.

PK/PD relationship:

Efficacy mainly depends on the relation between the maximum concentration in serum (Cmax) and the minimum inhibitory concentration (MIC) of ciprofloxacin for a bacterial pathogen and the relation between the area under the curve (AUC) and the MIC.

Mechanism of resistance:

In-vitro resistance to ciprofloxacin can be acquired through a stepwise process by target site mutations in both DNA gyrase and topoisomerase IV. The degree of cross-resistance between ciprofloxacin and other fluoroquinolones that results is variable. Single mutations may not result in clinical resistance, but multiple mutations generally result in clinical resistance to many or all active substances within the class.

Impermeability and/or active substance efflux pump mechanisms of resistance may have a variable effect on the susceptibility to fluoroquinolones, which depends on physiochemical properties of the various active substances within the class and the affinity of transport systems for each active substance. All in-vitro mechanisms of resistance are commonly observed in clinical isolates. Resistance mechanisms that inactivate other antibiotics such as permeation barriers (common in Pseudomonas aeruginosa) and efflux mechanisms may affect susceptibility to ciprofloxacin.

Plasmid mediated resistance encoded by qnr-genes has been reported.

Spectrum of antibacterial activity:

Breakpoints separate susceptible strains from strains with intermediate susceptibility and the latter from resistant strains:

EUCAST Recommendations

Microorganisms	Susceptible	Resistant
Enterobacteria	S <0.5mg/L	R > 1mg/L
Pseudomonas	S <0.5mg/L	R > 1mg/L
Acinetobacter	S <1mg/L	R > 1mg/L
Staphylococcus spp.1	S <1mg/L	R > 1mg/L
Haemophilus influenzae and Moraxella catarrhalis	S <0.5mg/L	R > 0.5mg/L
Neisseria gonorrhoeae	S <0.03mg/L	R > 0.06mg/L
Neisseria meningitidis	S <0.03mg/L	R > 0.06mg/L
Non-species-related breakpoints1	S <0.5mg/L	R > 1mg/L

¹ Staphylococcus spp. - breakpoints for ciprofloxacin relate to high dose therapy.

5.2 Pharmacokinetic properties

Absorption

Following oral administration of single doses of 250mg, 500mg and 750mg of ciprofloxacin tablets, ciprofloxacin is absorbed rapidly and extensively, mainly from the small intestine, reaching maximum serum concentrations 1-2 hours later.

Single doses of 100-750mg produced dose-dependent maximum serum concentrations (C_max) between 0.56 and 3.7mg/L. Serum concentration increase proportionately with doses up to 1000mg.

The absolute bioavailability is approximately 70 - 80%.

A 500mg oral dose given every 12 hours has been shown to produce an area under the serum concentration-time curve (AUC) equivalent to that produced by an intravenous infusion of 400mg ciprofloxacin given over 60 minutes every 12 hours.

Distribution

Protein binding of ciprofloxacin is low (20-30%). Ciprofloxacin is present in plasma largely in a non-ionised form and has a large steady state distribution volume of 2 - 3 L/kg body weight. Ciprofloxacin reaches high concentrations in a variety of tissues such as lung (epithelial fluid, alveolar macrophages, biopsy tissue), sinuses, inflamed lesions (cantharides blister fluid), and the urogenital tract (urine, prostate, endometrium) where total concentrations exceeding those of plasma concentrations are reached.

Biotransformation

Low concentrations of four metabolites have been reported, which were identified as: desethyleneciprofloxacin (M 1), sulphociprofloxacin (M 2), oxociprofloxacin (M 3) and formylciprofloxacin (M 4). The metabolites display in-vitro antimicrobial activity but to a lower degree than the parent compound.

Ciprofloxacin is known to be a moderate inhibitor of the CYP 450 1A2 isoenzymes.

Elimination

Ciprofloxacin is largely excreted unchanged both renally and, to a smaller extent, faecally. The serum elimination half-life in subjects with normal renal function is approximately 4 - 7 hours.

Excretion after oral administration (in % of ciprofloxacin dose):

Urine Faeces Ciprofloxacin    44.7    25.0

Metabolites    11.3    7.5

Renal clearance is between 180-300mL/kg/h and the total body clearance is between 480-600mL/kg/h. Ciprofloxacin undergoes both glomerular filtration and tubular secretion. Severely impaired renal function leads to increased halflives of ciprofloxacin up to 12 h.

Non-renal clearance of ciprofloxacin is mainly due to active trans-intestinal secretion and metabolism. 1% of the dose is excreted via the biliary route. Ciprofloxacin is present in the bile in high concentrations.

Paediatric patients

The pharmacokinetic data in paediatric patients are limited.

In a study in children C_max and AUC were not age-dependent (above one year of age). No notable increase in C_max and AUC upon multiple dosing (10mg/kg three times daily) was observed.

In 10 children with severe sepsis C_max was 6.1mg/L (range 4.6-8.3mg/L) after a 1-hour intravenous infusion of 10mg/kg in children aged less than 1 year compared to 7.2mg/L (range 4.7-11.8mg/L) for children between 1 and 5 years of age. The AUC values were 17.4mg*h/L (range 11.8-32.0mg*h/L) and 16.5mg*h/L (range 11.0-23.8mg*h/L) in the respective age groups.

These values are within the range reported for adults at therapeutic doses. Based on population pharmacokinetic analysis of paediatric patients with various infections, the predicted mean half-life in children is approx. 4-5 hours and the bioavailability of the oral suspension ranges from 50 to 80%.

5.3 Preclinical safety data

Non-clinical data reveal no special hazards for humans based on conventional studies of single dose toxicity, repeated dose toxicity, carcinogenic potential, or toxicity to reproduction. Like a number of other quinolones, ciprofloxacin is phototoxic in animals at clinically relevant exposure levels. Data on photomutagenicity/photocarcinogenicity show a weak photomutagenic or phototumorigenic effect of ciprofloxacin in-vitro and in animal experiments. This effect was comparable to that of other gyrase inhibitors.

Articular tolerability:

As reported for other gyrase inhibitors, ciprofloxacin causes damage to the large weight-bearing joints in immature animals. The extent of the cartilage damage varies according to age, species and dose; the damage can be reduced by taking the weight off the joints. Studies with mature animals (rat, dog) revealed no evidence of cartilage lesions. In a study in young beagle dogs, ciprofloxacin caused severe articular changes at therapeutic doses after two weeks of treatment, which were still observed after 5 months.

6    PHARMACEUTICAL PARTICULARS

6.1    List of excipients

For the Core:

Cellulose microcrystalline Sodium Starch Glycolate Starch Maize

Silica Colloidal anhydrous Magnesium stearate

For the Film-Coating:

Opadry OY 58900 White:

Hydroxypropyl Methylcellulose (hypromellose) Titanium Dioxide (E171)

Macrogol 400

6.2    Incompatibilities

Not applicable

6.3    Shelf life

3 years (36 months)

6.4    Special precautions for storage

Do not store above 25°C.

Keep in the original container.

6.5    Nature and contents of container

Alu/PVC blister of 10, 20 and 100 tablets

High density polyethylene tablet container closed with child resistant screw cap of 50, 100 and 500 tablets.

6.6    Special precautions for disposal

None

7    MARKETING AUTHORISATION HOLDER

Dr Reddy’s Laboratories (UK) Ltd

6 Riverview Road

Beverley

HU17 0LD

UK

8    MARKETING AUTHORISATION NUMBER(S)

PL 08553/0173

9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

28/03/2002

31/12/2015

1

Non-species-related breakpoints have been determined mainly on the basis of PK/PD data and are independent of MIC distributions of specific species. They are for use only for species that have not been given a species-specific breakpoint. and not for those species where susceptibility testing is not recommended.

The prevalence of acquired resistance may vary geographically and with time for selected species and local information on resistance is desirable, particularly when treating severe infections. As necessary, expert advice should be sought when the local prevalence of resistance is such that the utility of the agent in at least some types of infections is questionable.

Groupings of relevant species according to ciprofloxacin susceptibility (for Streptococcus species see section 4.4)