Ciprofloxacin 250mg Film-Coated Tablets
SUMMARY OF PRODUCT CHARACTERISTICS
1 NAME OF THE MEDICINAL PRODUCT
Ciprofloxacin 250mg Film-coated Tablets
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
Each tablet contains ciprofloxacin 250mg as the hydrochloride.
For excipients see 6.1.
3 PHARMACEUTICAL FORM
Film-coated tablets.
White or yellowish, scored, 11mm round, biconvex, film-coated tablets. Marked C250.
4 CLINICAL PARTICULARS
4.1 Therapeutic indications
Ciprofloxacin 500 mg 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 gonarrhoeae
• Epididymo-orchitis including cases due to susceptible Neisseria gonorrhoeae
• Pelvic inflammatory disease including cases due to susceptible Neisseria gonorrhoeae
In the above genital tract infections when thought or known to be due to Neisseria gonorrhoeae it is particularly important to obtain local information on the prevalence of resistance to ciprofloxacin and to confirm susceptibility based on laboratory testing.
• 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
• Treatment of infections in neutropenic patients
• Prophylaxis of infections in neutropenic patients
• Prophylaxis of invasive infections due to Neisseria meningitides
• 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.
Paediatric population
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 the 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 750 mg twice daily |
7 to 14 days | |
|
Infections of the upper respiratory tract |
Acute exacerbation of chronic sinusitis |
500 mg twice daily to 750 mg twice daily |
7 to 14 days |
|
Chronic suppurative otitis media |
500 mg twice daily to 750 mg twice daily |
7 to 14 days | |
|
Malignant external otitis |
750 mg twice daily |
28 days up to 3 months | |
|
Urinary tract infections |
Uncomplicated cystitis |
250mg twice daily to 500 mg twice daily |
3 days |
|
Indications |
Daily dose in mg |
Total duration of treatment (potentially including initial parenteral treatment with ciprofloxacin) | |
|
In pre-menopausal women, 500 mg single dose may be used | |||
|
Complicated cystitis, Uncomplicated pyelonephritis |
500 mg twice daily |
7 days | |
|
Complicated pyelonephritis |
500 mg twice daily to 750 mg twice daily |
at least 10 days, it can be continued for longer than 21 days in some specific circumstances (such as abscesses) | |
|
Prostatitis |
500 mg twice daily to 750 mg twice daily |
2 to 4 weeks (acute) to 4 to 6 weeks (chronic) | |
|
Genital tract infections |
Gonococcal uretritis and cervicitis |
500 mg as a single dose |
1 day (single dose) |
|
Epididymo-orchitis and pelvic inflammatory diseases |
500 mg twice daily to 750 mg twice daily |
at least 14 days | |
|
Infections of the gastrointestinal tract and intraabdominal infections |
Diarrhoea caused by bacterial pathogens including Shigella spp. other than Shigella dysenteriae type 1 and empirical |
500 mg twice daily |
1 day |
|
Indications |
Daily dose in mg |
Total duration of treatment (potentially including initial parenteral treatment with ciprofloxacin) | |
|
treatment of severe travellers’ diarrhoea | |||
|
Diarrhoea caused by Shigella dysenteriae type 1 |
500 mg twice daily |
5 days | |
|
Diarrhoea caused by Vibrio cholerae |
500 mg twice daily |
3 days | |
|
Typhoid fever |
500 mg twice daily |
7 days | |
|
Intra-abdominal infections due to Gram-negative bacteria |
500 mg twice daily to 750 mg twice daily |
5 to 14 days | |
|
Infections of the skin and soft tissue |
500mg twice daily to 750 mg twice daily |
7 to 14 days | |
|
Bone and joint infections |
500 twice daily to750 mg twice daily |
max. of 3 months | |
|
Treatment of infections or prophylaxis of infections in neutropenic patients Ciprofloxacin should be coadministered with appropriate antibacterial agent(s) in accordance to official guidance. |
500 mg twice daily to 750 mg twice daily |
Therapy should be continued over the entire period of neutropenia | |
|
Prophylaxis of invasive infections due to Neisseria meningitidis |
500 mg as a single dose |
1 day (single dose) | |
|
Indications |
Daily dose in mg |
Total duration of treatment (potentially including initial parenteral treatment with ciprofloxacin) |
|
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 |
500 mg 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 |
20 mg/kg body weight twice daily with a maximum of 750 mg per dose |
10 to 14 days |
|
Complicated urinary tract infections and pyelonephritis |
10 mg/kg body weight twice daily to 20 mg/kg body weight twice daily with a maximum of 750 mg per dose |
10 to 21 days |
|
Indications |
Daily dose in mg |
Total duration of treatment (potentially including initial parenteral treatment with ciprofloxacin) |
|
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 |
10 mg/kg body weight twice daily to 15 mg/kg body weight twice daily with a maximum of 500 mg per dose |
60 days from the confirmation of Bacillus anthracis exposure |
|
Other severe infections |
20 mg/kg body weight twice daily with a maximum of 750 mg 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.
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 |
250-500 mg every 12 h |
|
< 30 |
> 169 |
250-500 mg every 24 h |
|
Patients on haemodialysis |
> 169 |
250-500 mg every 24 h (after dialysis) |
|
Patients on peritoneal dialysis |
> 169 |
250-500 mg 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:
The tablets are to be swallowed unchewed with fluid. They can be taken independent of meal times. 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
|
Creatinine clearance [mL/min/1.73 m2] |
Serum creatinine [pmol/L] |
Oral Dose [mg] |
Contraindications
• Hypersensitivity to the active substance, to other quinolones or to any of the excipients (see 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 pneumoniae)
Ciprofloxacin is not recommended for the treatment of streptococcal infections due to inadequate efficacy.
Genital tract infections
Gonococcal urethritis, cervicitis, epididymo-orchitis and pelvic inflammatory diseases 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 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 on 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 guidance, 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 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 the 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. 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 aggravated (see section 4.8).
Vision disorders
If vision becomes impaired or any effects on the eyes are experienced, an eye specialist should be consulted immediately.
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/thought 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, section 4.5, section 4.8, 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 Pseudomonas species.
Cytochrome P450
Ciprofloxacin inhibits CYP1A2 and thus may cause increased serum concentration of concomitantly administered substances metabolised 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.
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 and III anti-arrhythmics, 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), 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 these preparations. 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 Cmax 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 (Cmax 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 (oxpentifylline), 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.
Ciclosporin
A transient rise in the concentration of serum creatinine was observed when ciprofloxacin and ciclosporin 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. There have been many reports of increases in oral anticoagulant activity in patients receiving antibacterial agents, including fluoroquinolones. The risk may vary with the underlying infection, age and general status of the patient so that the contribution of the fluoroquinolone to the increase in INR (international normalised ratio) is difficult to assess. It is recommended that the INR should be monitored frequently during and shortly after co-administration 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 Cmax 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 Cmax 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 coadministration with ciprofloxacin are advised (see section 4.4).
Sevelamer
The bioavailability of ciprofloxacin is reduced by the concomitant administration with sevelamer (up to 50%), therefore, it is recommended that the two should not be taken concomitantly.
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 the 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 (see ‘Cytochrome P450’ in section 4.4).
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 foeto/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
4.8. Undesirable effects
a) Summary of the safety profile
The most commonly reported adverse drug reactions (ADRs) are nausea and diarrhoea.
b) Tabulated list of adverse reactions
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 / angioedema |
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 ideations/thoughts or suicide attempts and completed suicide) (see section 4.4) Hallucinations |
Psychotic reactions (potentially culminating in suicidal ideations/ thoughts or suicide attempts and completed suicide) (see section 4.4) |
Mania Hypomania |
|
System Organ |
Common |
Uncommon |
Rare |
Very Rare |
Frequency |
|
Class |
> 1/100 |
> 1/1 000 to < |
> 1/10 000 to < |
< 1/10 000 |
not known |
|
to < 1/10 |
1/100 |
1/1 000 |
(cannot be estimated from available data) | ||
|
Nervous |
Headache |
Par- and |
Migraine |
Peripheral | |
|
System Disorders |
Dizziness |
Dysaesthesia |
Disturbed |
neuropathy anc polyneuropathy | |
|
Sleep disorders |
Hypoaesthesia |
coordination |
(see section | ||
|
Taste disorders |
Tremor |
Gait |
4.4) | ||
|
Seizures (including status epilepticus (see |
disturbance | ||||
|
section 4.4) |
Olfactory | ||||
|
nerve | |||||
|
Vertigo |
disorders Intracranial | ||||
|
hypertension and |
|
pseudotumour cerebri | |||||
|
Eye Disorders |
Visual disturbances |
Visual colour distortions | |||
|
Ear and Labyrinth Disorders |
Tinnitus Hearing loss / Hearing impaired | ||||
|
Cardiac Disorders |
Tachycardia |
Ventricular arrhythmia and torsades de pointes (reporte< predominantly in patients with risk factors for QT prolongation), ECG QT prolonged (see section 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 pseudomembranous colitis (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) |
|
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) |
|
Skin and Subcutaneous Tissue Disorders |
Rash Pruritus Urticaria |
Photosensitivity reactions (see section 4.4) |
Petechiae Erythema multiforme Erythema nodosum |
Acute generalised exanthematous pustulosis (AGEP) | |
|
Stevens- Johnson syndrome (potentially life- threatening) Toxic epidermal necrolysis (potentially life- threatening) |
Drug Reaction with Eosinophilia and Systemic Symptoms (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 |
Renal |
Renal failure |
|
Urinary Disorders |
impairment |
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 |
Prothrombin level abnormal Increased amylase |
International normalised ratio increased (in patients treated with Vitamin K antagonists) |
Paediatric population
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 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,
Website: www.mhra.gov.uk/yellowcard
4.9. Overdose
An overdose of 12 g has been reported to lead to mild symptoms of toxicity. An acute overdose of 16 g has been reported to cause acute renal failure.
Symptoms in overdose consist of dizziness, tremor, headache, 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, it is recommended to monitor renal function, including urinary pH and acidify, if required, to prevent crystalluria.
Patients should be kept well hydrated. 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
Therapeutic classification: J 01 MA 02
Activity:
Ciprofloxacin is a synthetic 4-quinolone derivative antibacterial agent of the fluoroquinolone class.
Mechanism of action:
As a fluoroquinolone antibacterial agent, ciprofloxacin acts on the DNA-DNA-gyrase complex and topoisomerase IV.
Spectrum of activity:
Breakpoints:
BSAC: S < 1ml/L; R> 2mg/l, except Pseudomonas R > 8mg/ml and UTI R > 8mg/L. NCCLS: S < 1mg/l; I = 2mg/l; R > 4mg/l.
Susceptibility
The prevalence of the acquired resistances can vary for some species geographically and with time. Therefore, it is important to obtain information on local resistance patterns, particularly when treating more severe infections.
The information provided below gives only an approximate guidance on probabilities whether micro-organisms will be susceptible to ciprofloxacin or not.
|
Organism |
Prevalence of Resistance |
|
Sensitive: | |
|
Gram-positive bacteria | |
|
Staphylococcus aureus (methicillin sensitive) |
0 - 14% |
|
Streptococcus agalactiae |
0 - 17% |
|
Gram-negative bacteria | |
|
Acinetobacter baumanii |
6 - 93% |
|
Acinetobacter spp. |
14 - 70% |
|
Aeromonas hydrophila | |
|
Campylobacter jejuni/coli |
0 - 82% |
|
Citrobacter freundii |
0 - 4% |
|
Enterobacter aerogenes |
|
Enterobacter cloacae |
0 - 3% | |
|
Enterobacter spp |
3 - 13% | |
|
Escherichia coli |
2 -7% | |
|
Haemophilus influenzae |
0 - 1% | |
|
Klebsiella spp. |
2 - 21% | |
|
Moraxella catarrhalis | ||
|
Morganella morganii |
1 - 2% | |
|
Neisseria gonorrhoeae |
5% | |
|
Plesiomonas shigelloides | ||
|
Proteus mirabilis |
0 - 10% | |
|
Proteus vulgaris |
4% | |
|
Providencia spp. |
4% | |
|
Pseudomonas aeruginosa |
1 - 28% | |
|
Salmonella spp. | ||
|
Salmonella typhi |
0 - 2% | |
|
Serratia liquefaciens | ||
|
Serratia marcescens |
23% | |
|
Shigella spp | ||
|
Vibrio spp | ||
|
Yersinia enterocolitica | ||
|
Anaerobes1 | ||
|
Peptococcus spp. |
- | |
|
Peptostreptococcus spp. |
- | |
|
Veillonella parvula |
- | |
|
Other pathogens | ||
|
Legionella pneumophila |
- | |
|
Intermediate | ||
|
Viridans streptococci |
5-9% | |
|
Streptococcus pneumoniae |
2.8% | |
|
Streptococcus pyogenes |
2.8% | |
|
Other pathogens | ||
|
Chlamydia spp |
- | |
|
Resistant | ||
|
Gram-positive aerobes | ||
|
Enterococcus spp |
- | |
|
Staphylococcus aureus (methicillin resistant) |
48 - 90% | |
|
Gram-negative aerobes | ||
|
Stenotrophomonas maltophila |
- | |
|
Flavobacterium meningosepticum |
- | |
|
Nocardia asteroides |
- | |
|
Anaerobes | ||
|
Bacteroides fragilis |
- | |
|
Bacteroides thetaiotaomicron |
- | |
|
Clostridium difficile |
- | |
In-vitro investigations have shown that resistance to ciprofloxacin is commonly due to mutations in bacterial topoisomerases and usually develops slowly and gradually (“multiple-step” type).
Cross-resistance between fluoroquinolones may occur when the mechanism of resistance is due to mutations in bacterial gyrases. However, single mutations may not result in clinical resistance, but multiple mutations generally do result in clinical resistance to all drugs within the class. Impermeability and/or drug efflux pump mechanisms of resistance may have a variable effect on susceptibility to fluoroquinolones, which depends on the physicochemical properties of the various drugs within the class and the affinity of transport systems for each drug.
5.2 Pharmacokinetic properties
Absorption
After oral administration, ciprofloxacin is predominantly absorbed from the duodenum and upper jejunum and reaches peak serum concentrations within 60-90 min. After single doses of 250mg and 500mg Cmax values are about 0.8-2.0mg/l and 1.5-2.9mg/l respectively
The absolute bioavailability is approximately 70 to 80%. Cmax- and AUC-values are proportionally increased with the dose.
Food intake has no effect on the plasma concentration profile of ciprofloxacin. Distribution
The steady-state volume of distribution of ciprofloxacin is 2-3 l/kg. Since the protein binding of ciprofloxacin is low (20-30%) and the substance is predominantly present in the blood plasma in non-ionised form, almost the entire quantity of the administered dose can diffuse freely into the extravasal space. As a result, the concentrations in certain body fluids and tissues may be markedly higher than the corresponding serum concentrations.
Metabolism /Elimination
Ciprofloxacin is essentially excreted in unchanged form, mostly in the urine. Renal clearance lies between 3 and 5ml/min/kg, and total clearance amounts to 8-10ml/min/kg. Both glomerular filtration and tubular secretion play a part in the elimination of ciprofloxacin.
Small concentrations of 4 metabolites were found: desethylene ciprofloxacin (M 1), sulphociprofloxacin (M 2), oxociprofloxacin (M 3) and formylciprofloxacin (M 4). M 1 to M 3 show antibacterial activity comparable with or smaller than nalidixic acid. M 4 with the lowest quantity, has an antimicrobial activity very much corresponding to norfloxacin.
Excretion after oral administration (in % of the ciprofloxacin dose):
urine faeces
Ciprofloxacin
44.7
25.0
Metabolites
11.3
7.5
The half-life of ciprofloxacin lies between 3 and 5 hours, both after oral and after intravenous administration.
Since ciprofloxacin is excreted not only via the kidneys, but also to a major extent via the gut, renal function must be substantially impaired before increases in serum elimination half-life of up to 12 hours are observed.
5.3 Preclinical safety data
Like other gyrase inhibitors, ciprofloxacin may induce joint damage during the growth phase of juvenile animals. Other preclinical effects were observed only at exposures, sufficiently in excess of the maximum human exposure, that make concern for human safety negligible in respect of animal data.
6 PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Tablet core:
Microcrystalline cellulose Crospovidone Silica colloidal anhydrous Magnesium stearate
Film coating:
Hypromellose Macrogol 400 Titanium dioxide (E171)
6.2 Incompatibilities
Not Applicable
6.3 Shelf life
36 months.
6.4 Special precautions for storage
Do not store above 25 °C. Store in the original packaging.
6.5 Nature and contents of container
Blister strips of 20 pm Aluminium and 250 pm PVC in a cardboard outer container. Pack sizes: 10, 20 or 100 tablets.
6.6 Special precautions for disposal
None.
7 MARKETING AUTHORISATION HOLDER
Wockhardt UK Ltd Ash Road North Wrexham LL13 9UF U.K.
8 MARKETING AUTHORISATION NUMBER(S)
PL 29831/0310
9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
11/02/2009
10 DATE OF REVISION OF THE TEXT
15/09/2016
Ciprofloxacin is not considered the drug of first choice for treatment of infections with anaerobes.