Galpharm Allergy Relief 1mg/Ml Syrup
SUMMARY OF PRODUCT CHARACTERISTICS
1. NAME OF THE MEDICINAL PRODUCT
Galpharm Allergy Relief 1mg/mL Syrup
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
Each 1 ml of solution contains 1 mg of cetirizine hydrochloride. Excipients:
Galpharm Allergy Relief 1mg/mL Syrup contains 315 mg sorbitol per ml. For full list of excipients, see section 6.1.
3. PHARMACEUTICAL FORM
Oral solution.
Clear colourless solution.
4.1. Therapeutic indications
In adults and paediatric patients 2 years and above:
• Cetirizine is indicated for the relief of nasal and ocular symptoms of seasonal and perennial rhinitis.
• Cetirizine is indicated for the relief of symptoms of chronic idiopathic urticaria.
4.2. Posology and method of administration
For oral use.
Adults and adolescents over 12 years of age: 2 x 5ml once daily.
If drowsiness occurs, the solution can be administered in the evening.
Children 6-12 years:
2 x 5ml once daily or 5ml taken twice daily (morning and evening).
Children 2-6 years or weighing less than 30 Kg:
5ml taken once daily or 2.5ml twice daily.
At present there is insufficient clinical data to recommend the use of cetirizine in children under 2 years of age.
Elderly patients: data do not suggest that the dose needs to be reduced in elderly subjects provided that the renal function is normal.
Patients with moderate to severe renal impairment: there are no data to document the efficacy/safety ratio in patients with renal impairment. Since cetirizine is mainly excreted via renal route (see section 5.2), in cases no alternative treatment can be used, the dosing intervals must be individualized according to renal function. Refer to the following table and adjust the dose as indicated. To use this dosing table, an estimate of the patient’s creatinine clearance (CLcr) in ml/min is needed. The CLcr (ml/min) may be estimated from serum creatinine (mg/dl) determination using the following formula.
Clcr = r 140 - age (years)] x weight (kg) (x 0.85 for women)
72 x serum creatinine (mg/dl)
Dosing adjustment for adult patients with impaired renal function.
|
Group |
Creatinine clearance (ml/min) |
Dosage and frequency |
|
Normal |
>80 |
10 mg once daily |
|
Mild |
50 - 79 |
10 mg once daily |
|
Moderate |
30 - 49 |
5 mg once daily |
|
Severe |
<30 |
5 mg once every 2 days |
|
End-stage renal disease |
<10 |
Contra-indicated |
|
- Patients undergoing | ||
|
dialysis |
In paediatric patients suffering from renal impairment, the dose will have to be adjusted on an individual basis taking into account the renal clearance of the patient, his age and his body weight.
Patients with hepatic impairment: no dose adjustment is needed in patients with solely hepatic impairment.
Patients with hepatic impairment and renal impairment: dose adjustment is recommended (see Patients with moderate to severe renal impairment above)
4.3. Contraindications
History of hypersensitivity to any of the constituents of the formulation, to
hydroxyzine or to any piperazine derivatives.
Patients with severe renal impairment at less than 10ml/min creatinine clearance.
4.4. Special warnings and precautions for use
In some patients, long term treatment with Cetirizine Solution may lead to an increased risk of caries due to mouth dryness. The patients should therefore be informed about the importance of oral hygiene.
At therapeutic doses, no clinically significant interactions have been demonstrated with alcohol (for a blood alcohol level of 0.5g/L). Nevertheless, precaution is recommended if alcohol is taken concomitantly.
Caution should be taken in patients with predisposition factors of urinary retention (e.g. spinal cord lesion, prostatic hyperplasia) as cetirizine may increase the risk of urinary retention.
Caution in epileptic patients and patients at risk of convulsions is recommended,
Methyl parahydroxybenzoate and propyl parahydroxybenzoate may cause allergic reactions (possibly delayed)
Patients with rare hereditary problems of fructose intolerance should not take cetirizine 1mg/ml oral solution.
Allergy skin tests are inhibited by antihistamines and a wash-out period (of 3 days) is required before performing them.
Patients with impaired renal function, please see sections 4.2 and 4.3
4.5. Interactions with other medicinal products and other forms of interaction
Due to the pharmacokinetic, pharmacodynamic and tolerance profile of cetirizine, no interactions are expected with this antihistamine. Actually, neither pharmacodynamics nor significant pharmacokinetic interaction was reported in drug-drug interactions studies performed, notably with pseudoephedrine or theophylline (400 mg/day).
The extent of absorption of cetirizine is not reduced with food, although the rate of absorption is decreased.
4.6. Pregnancy and lactation
Pregnancy
For Cetirizine very rare clinical data on exposed pregnancies are available. Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/fetal development, parturition or postnatal development. Caution should be exercised when prescribing to pregnant women.
Breast feeding
Cetirizine is excreted in human milk at concentraions representing 25% to 90% of those measured in plasma, depending on sampling time after administration. Therefore, caution should be exercised when prescribing cetirizine to lactating women.
4.7. Effects on ability to drive and use machines
Objective measurements of driving ability, sleep latency and assembly line performance have not demonstrated any clinically relevant effects at the recommended dose of 10mg.
Patients intending to drive, engaging in potentially hazardous activities or operating machinery should not exceed the recommended dose and should take their response to the medicinal product into account.
In sensitive patients, concurrent use with alcohol or other CNS depressants may cause additional reductions in alertness and impairment of performance.
4.8. Undesirable effects
Clinical studies have shown that cetirizine at the recommended dosage has minor undesirable effects on the CNS, including somnolence, fatigue, dizziness and headache. In some cases, paradoxical CNS stimulation has been reported.
Although cetirizine is a selective antagonist of peripheral H1-receptors and is relatively free of anticholinergic activity, isolated cases of micturition difficulty, eye accommodation disorders and dry mouth have been reported.
Instances of abnormal hepatic function with elevated hepatic enzymes accompanied by elevated bilirubin have been reported. Mostly this resolves upon discontinuation of the treatment with cetirizine dihydrochloride.
Clinical Trials
Double blind controlled clinical trials comparing cetirizine to placebo or other antihistamines at the recommended dosage (10 mg daily for cetirizine), of which quantified safety data are available, included more than 3200 subjects exposed to cetirizine.
From this pooling, the following adverse events were reported for cetirizine 10 mg in the placebo controlled trials at rates of 1.0 % or greater.
|
Adverse reactions (WHO-ART) |
Cetirizine 10 mg (n = 3260) |
Placebo (n = 3061) |
|
Body as a whole - general |
|
disorders Fatigue |
1.63 % |
0.95 % |
|
Central and peripheral nervous system disorders Dizziness |
1.10 % |
0.98 % |
|
Headache |
7.42 % |
8.07 % |
|
Gastro-intestinal system disorders Abdominal pain |
0.98 % |
1.08 % |
|
Dry mouth |
2.09 % |
0.82 % |
|
Nausea |
1.07 % |
1.14 % |
|
Psychiatric disorders Somnolence |
9.63 % |
5.00 % |
|
Respiratory system disorders |
1.29 % |
1.34 % |
|
Pharyngitis |
Although statistically more common than under placebo, somnolence was mild to moderate in the majority of cases. Objective tests as demonstrated by other studies have demonstrated that usual daily activities are unaffected at the recommended daily dose in healthy young volunteers.
Adverse reactions at rates of 1 % or greater in children aged from 6 months to 12 years, included in placebo-controlled clinical trials are:
|
Adverse reactions (WHO-ART) |
Cetirizine (n = 1656) |
Placebo (n = 1294) |
|
Gastro-intestinal system disorders Diarrhoea |
1.0 % |
0.6 % |
|
Psychiatric disorders Somnolence |
1.8 % |
1.4 % |
|
Respiratory system disorders Rhinitis |
1.4 % |
1.1 % |
|
Body as a whole -general disorders Fatigue |
1.0 % |
0.3 % |
Post-marketing experience
In addition to the adverse reactions reported during clinical studies and listed above, the following undesirable effects have been reported in post-marketing experience.
Undesirable effects are described according to MedDRA System Organ Class and by estimated frequency based on post-marketing experience.
Frequencies are defined as follows:
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 (cannot be estimated from the available data)
Blood and lymphatic disorders:
Very rare: thrombocytopenia
Immune system disorders:
Rare: hypersensitivity Very rare: anaphylactic shock
Metabolism and nutrition disorders:
Not known: increased appetite.
Psychiatric disorders:
Uncommon: agitation
Rare: aggression, confusion, depression, hallucination, insomnia Very rare: tics
Not known: suicidal ideation
Nervous system disorders:
Uncommon: paraesthesia Rare: convulsions
Very rare: dysgeusia, syncope, tremor, dystonia, dyskinesia Not known: amnesia, memory impairment
Eye disorders:
Very rare: accommodation disorder, blurred vision, oculogyration
Ear and labyrinth disorders:
Not known: vertigo
Cardiac disorders:
Rare: tachycardia
Gastro-intestinal disorders:
Uncommon: diarrhoea
Hepatobiliary disorders:
Rare: hepatic function abnormal (increased transaminases, alkaline phosphatise, y-GT and bilirubin)
Skin and subcutaneous tissue disorders:
Uncommon: pruritus, rash Rare: urticaria
Very rare: angioneurotic oedema, fixed drug eruption
Renal and urinary disorders:
Very rare: dysuria, enuresis
Not known: urinary retention
General disorders and administration site conditions:
Uncommon: asthenia, malaise Rare: oedema
Investigations:
Rare: weight increased
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 reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.
4.9. Overdose
Symptoms
Symptoms observed after an overdose of cetirizine are mainly associated with CNS effects or with effects that could suggest an anticholinergic effect.
Adverse events reported after an intake of at least 5 times the recommended daily dose are: confusion, diarrhoea, dizziness, fatigue, headache, malaise, mydriasis, pruritus, restlessness, sedation, somnolence, stupor, tachycardia, tremor and urinary retention.
Management
There is no known specific antidote to cetirizine.
Should overdose occur, sympotomatic or supportive treatment is recommended. Gastric lavage should be considered following ingestion of a short occurrence.
Cetirizine is not effectively removed by dialysis.
5.1. Pharmacodynamic properties
Pharmacotherapeutic group: Piperazine derivatives, ATC code: R06A E07
Cetirizine, a human metabolite of hydroxyzine, is a potent and selective antagonist of peripheral H1-receptors. In vitro receptor binding sites have shown no measurable affinity for other than H1-receptors.
In addition to its anti-H1 effect, cetirizine was shown to display anti-allergic activities: at a dose of 10 mg once or twice daily, it inhibits the late phase recruitment of eosinophils, in the skin and conjunctiva of atopic subjects submitted to allergen challenge.
Studies in healthy volunteers show that cetirizine, at doses of 5 and 10 mg strongly inhibits the wheal and flare reactions induced by very high concentrations of histamine into the skin, but the correlation with efficacy is not established.
In a 35-day study in children aged 5 - 12, no tolerance to the antihistaminic effect (suppression of wheal and flare) of cetirizine was found. When a treatment with cetirizine is stopped after repeated administration, the skin recovers its normal reactivity to histamine within 3 days.
In a six-week, placebo-controlled study of 186 patients with allergic rhinitis and concomitant mild to moderate asthma, cetirizine 10 mg once daily improved rhinitis symptoms and did not alter pulmonary function. This study supports the safety of administering cetirizine to allergic patients with mild to moderate asthma.
In a placebo-controlled study, cetirizine given at the high daily dose of 60 mg for seven days did not cause statistically significant prolongation of QT interval.
At recommended dosage, cetirizine has demonstrated that it improves the quality of life of patients with perennial and seasonal allergic rhinitis.
5.2. Pharmacokinetic properties
The steady-state peak plasma concentration is approximately 300 mg/ml and is achieved within 1.0 ± 0.5 h. No accumulation is observed for cetirizine following daily doses of 10 mg for 10 days. The distribution of pharmacokinetic parameters such as peak plasma concentration (Cmax) and area under curve (AUC) is unimodal in human volunteers.
The extent of absorption of cetirizine is not reduced with food, although the rate of absorption is decreased. The extent of bioavailability is similar when cetirizine is given as solutions, capsules or tablets.
The apparent volume of distribution is 0.50 l/kg. Plasma protein binding of cetirizine is 93 ± 0.3 %.
Cetirizine does not modify the protein binding of warfarin.
Cetirizine does not undergo extensive first pass metabolism. About two thirds of the dose are excreted unchanged in urine. The terminal half-life is approximately 10 hours.
Cetirizine exhibits linear kinetics over the range of 5 to 60 mg.
Special populations
Elderly: following a single 10 mg oral dose, half-life increased by about 50% and clearance decreased by 40% in 16 elderly subjects compared to the normal
subjects. The decrease in cetirizine clearance in these elderly volunteers appeared to be related to their decreased renal function.
Children, infants and toddlers: The half-life of cetirizine was about 6 hours in children of 6 - 12 years and 5 hours in children 2 - 6 years. In infants and toddlers aged 6 to 24 months, it is reduced to 3.1 hours.
Renally impaired patients: The pharmacokinetics of the drug were similar in patients with mild impairment (creatinine clearance higher than 40 ml/min) and healthy volunteers. Patients with moderate renal impairment had a 3-fold increase in half-life and 70% decrease in clearance compared to healthy volunteers.
Patients on hemodialysis (creatinine clearance less than 7 ml/min) given a single oral 10 mg dose of cetirizine had a 3-fold increase in half-life and a 70% decrease in clearance compared to normal.
Cetirizine was poorly cleared by hemodialysis. Dosing adjustment is necessary in patients with moderate or severe renal impairment (see section 4.2).
Hepatically impaired patients: Patients with chronic liver disease (hepatocellular, cholestatic, and biliary cirrhosis) given 10 or 20 mg of cetirizine as a single dose had a 50% increase in half-life along with a 40% decrease in clearance compared to healthy subjects.
Dosing adjustment is only necessary in hepatically impaired patients if concomitant renal impairment is present.
5.3. Preclinical safety data
Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential, toxicity to reproduction.
6. PHARMACEUTICAL PARTICULARS
6.1. List of excipients
Glycerol Propylene glycol
Liquid Sorbitol (non-crystallising) (E420)
Methyl Parahydroxybenzoate (E218)
Propyl Parahydroxybenzoate (E216)
Sodium acetate Acetic acid Saccharin sodium Banana flavour Purified water
6.2. Incompatibilities
Not applicable.
6.3. Shelf life
3 years.
6.4. Special precautions for storage
No special precautions for storage.
6.5. Nature and contents of container
70, 75, 100, 150 and 200ml fill bottles.
Amber glass bottle with child-resistant polypropylene screw cap incorporating a tamper evident seal (yellow polyethylene).
Measuring device: 5ml plastic PP measuring spoon graduated at 2.5ml
6.6 Special precautions for disposal Not Applicable
7. MARKETING AUTHORISATION HOLDER
Galpharm Healthcare Limited
Wrafton
Braunton
Devon
EX33 2DL
United Kingdom
8. MARKETING AUTHORISATION NUMBER
PL 16028/0097
9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
13/10/2011
10 DATE OF REVISION OF THE TEXT
04/05/2016