SUMMARY OF PRODUCT CHARACTERISTICS

1 NAME OF THE MEDICINAL PRODUCT

‘Indocid’ Suppositories 100 mg

2 QUALITATIVE AND QUANTITATIVE COMPOSITION

‘Indocid’ Suppositories contains 100 mg of indomethacin.

3    PHARMACEUTICAL FORM

‘Indocid’ is available in polyethylene glycol suppositories.

4 CLINICAL PARTICULARS

4.1 Therapeutic indications

Non-steroidal anti-inflammatory agent indicated for the active stages of rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, acute musculoskeletal disorders, degenerative joint disease of the hip, low-back pain, and acute gouty arthritis.

Also indicated in inflammation, pain and oedema following orthopaedic procedures; and the treatment of pain and associated symptoms of primary dysmenorrhoea.

‘Indocid’ Suppositories may be used where night pain and morning stiffness are prominent. One suppository at bedtime will frequently give relief from pain and stiffness for 13 to 16 hours after administration.

4.2 Posology and method of administration

The dosage of ‘Indocid’ should be carefully adjusted to suit the needs of the individual patient.

Adult dosage for suppositories: One suppository to be inserted once or twice a day. One should be used at bedtime. If another is necessary, it should be used in the morning.

Use in the elderly: ‘Indocid’ should be used with particular care in older patients who are more prone to adverse reactions.

4.3 Contraindications

A history of peptic ulcer or active peptic ulcer; a recurrent history of gastro-intestinal lesions; in patients who have nasal polyps associated with angioneurotic oedema, who show sensitivity to indomethacin or any of the ingredients in this product, or who have experienced acute asthmatic attacks, urticaria or rhinitis as a result of therapy with aspirin or other non-steroidal anti-inflammatory drugs.

Safety for use in children has not been established.

‘Indocid’ Suppositories are contra-indicated in patients with a history of proctitis or recent rectal bleeding.

Pregnancy and lactation: ‘Indocid’ should not be used during pregnancy or lactation (see section 4.6 ‘Pregnancy and lactation’).

4.4 Special warnings and precautions for use

Headache, sometimes accompanied by dizziness and light-headedness, may occur, usually early in treatment. Starting therapy with a low dosage and increasing it gradually will usually minimise the incidence of headache. These symptoms frequently disappear on continuing therapy or reducing the dosage, but if headache persists despite dosage reduction, ‘Indocid’ should be withdrawn. Patients should be warned that they may experience dizziness and, if they do, should not drive a car or undertake potentially dangerous activities needing alertness.

‘Indocid’ should be used cautiously in patients with a history of bronchial asthma and in patients with psychiatric disorders, epilepsy, or parkinsonism, as indomethacin may tend to aggravate these disorders.

Single or multiple ulcerations, including perforation and haemorrhage of the oesophagus, stomach, duodenum or small or large intestine, have been reported to occur with ‘Indocid’. Fatalities have been reported in some instances. Rarely, intestinal ulceration has been associated with stenosis and obstruction.

NSAIDs should only be given with care to patients with a history of gastrointestinal disease.

Gastro-intestinal bleeding without obvious ulcer formation and perforation of pre-existing sigmoid lesions (diverticulum, carcinoma, etc.) have occurred. Increased abdominal pain in ulcerative colitis patients or the development of ulcerative colitis and regional ileitis have been reported to occur rarely.

Fluid retention and peripheral oedema have been observed in some patients taking ‘Indocid’. ‘Indocid’ should therefore be used with caution in patients with cardiac dysfunction, hypertension or other conditions predisposing to fluid retention.

Tenesmus and irritation of the rectal mucosa have been reported occasionally with ‘Indocid’ Suppositories.

‘Indocid’ may mask the signs and symptoms of infection. ‘Indocid’ should be used with caution in patients with existing but controlled infection.

In patients with rheumatoid arthritis, eye changes may occur which may be related to the underlying disease or to the therapy. Therefore, in chronic rheumatoid disease, ophthalmological examinations at periodic intervals are recommended. Discontinue therapy if eye changes are observed.

Patients should be periodically observed to allow early detection of any unwanted effects on peripheral blood (anaemia), liver function, or gastro-intestinal tract.

‘Indocid’ can inhibit platelet aggregation. This effect usually disappears within 24 hours of discontinuing ‘Indocid’. Bleeding time is prolonged (but within normal range) in normal adults. Because this effect may be exaggerated in patients with underlying haemostatic defects, ‘Indocid’ should be used cautiously in patients with coagulation defects.

As with other non-steroidal anti-inflammatory drugs, there have been reports of acute interstitial nephritis with haematuria, proteinuria, and occasionally nephrotic syndrome in patients receiving long-term administration of indomethacin.

In patients with reduced renal blood flow where renal prostaglandins play a major role in maintaining renal perfusion, administration of a non-steroidal anti-inflammatory agent may precipitate overt renal decompensation. Patients at greatest risk of this reaction are those with renal or hepatic dysfunction, diabetes mellitus, advanced age, extracellular volume depletion, congestive heart failure, sepsis, or concomitant use of any nephrotoxic drug. A non-steroidal anti-inflammatory drug should be given with caution and renal function should be monitored in any patient who may have reduced renal reserve. Discontinuation of non-steroidal anti-inflammatory therapy is usually followed by recovery to the pretreatment state.

Increases in plasma potassium concentration, including hyperkalaemia, have been reported, even in some patients without renal impairment. In patients with normal renal function, these effects have been attributed to a hyporeninaemic-hypoaldosteronism state (see 4.5 ‘Interaction with other medicinal products and other forms of interactions’).

Since ‘Indocid’ is eliminated primarily by the kidneys, patients with significantly impaired renal function should be closely monitored; a lower daily dosage should be used to avoid excessive drug accumulation.

4.5 Interaction with other medicinal products and other forms of interaction

Aspirin:    the use of ‘Indocid’ with aspirin or other salicylates is not

recommended. Controlled clinical studies have shown no enhanced therapeutic effect, and one study showed a significant increase in the incidence of gastro-intestinal side effects. A study in normal volunteers showed that chronic administration of 3.6 g aspirin with indomethacin lowered the indomethacin blood levels by approximately 20%.

Diflunisal: co-administration of diflunisal with ‘Indocid’ increases the plasma level of indomethacin by about a third, with a concomitant decrease in renal clearance. Fatal gastro-intestinal haemorrhage has occurred. The combination should not be used.

Other NSAIDS: the concomitant use of ‘Indocid’ with other NSAIDs is not recommended due to the increased possibility of gastro-intestinal toxicity, with little or no increase in efficacy.

Anticoagulants: although clinical studies suggest that ‘Indocid’ does not influence the hypoprothrombinaemia induced by anticoagulants, patients also receiving anticoagulants should be closely observed for alterations of the prothrombin time.

Probenecid: co-administration of probenecid may increase plasma levels of indomethacin.

Methotrexate: caution should be exercised with simultaneous use of ‘Indocid’ with methotrexate. ‘Indocid’ has been reported to decrease the tubular secretion of methotrexate and to potentiate toxicity.

Cyclosporin:    administration of non-steroidal anti-inflammatory drugs

concomitantly with cyclosporin has been associated with an increase in cyclosporin-induced toxicity, possibly due to decreased synthesis of renal prostacyclin. NSAIDs should be used with caution in patients taking cyclosporin, and renal function should be monitored carefully.

Lithium: indomethacin 50 mg three times a day produced a clinically relevant elevation of plasma lithium and reduction in renal lithium clearance in psychiatric patients and normal subjects with steady-state plasma lithium concentrations. This effect has been attributed to inhibition of prostaglandin synthesis. As a consequence, when indomethacin and lithium are given concomitantly, the patient should be observed carefully for signs of lithium toxicity. In addition, the frequency of monitoring serum lithium concentrations should be increased at the outset of such combination drug treatment.

Diuretics: in some patients, the administration of ‘Indocid’ can reduce the diuretic and antihypertensive effects of loop, potassium-sparing and thiazide diuretics. Therefore, when ‘Indocid’ and diuretics are used concomitantly, the patient should be observed closely to determine if the desired effect of the diuretic is obtained.

‘Indocid’ reduces basal plasma renin activity (PRA), as well as those elevations of PRA induced by frusemide administration, or salt or volume depletion. These facts should be considered when evaluating plasma renin activity in hypertensive patients.

It has been reported that the addition of triamterene to a maintenance schedule of ‘Indocid’ resulted in reversible acute renal failure in two of four healthy volunteers. ‘Indocid’ and triamterene should not be administered together.

‘Indocid’ and potassium-sparing diuretics each may be associated with increased plasma potassium levels. The potential effects of ‘Indocid’ and potassium-sparing diuretics on potassium kinetics and renal function should be considered when these agents are administered concurrently.

Most of the above effects concerning diuretics have been attributed, at least in part, to mechanisms involving inhibition of prostaglandin synthesis by ‘Indocid’.

Cardiac glycosides/Digoxin: ‘Indocid’ given concomitantly with digoxin has been reported to increase the serum concentration and prolong the half-life of digoxin. Therefore, when ‘Indocid’ and digoxin are used concomitantly, serum digoxin levels should be closely monitored.

Antihypertensive medications: co-administration of ‘Indocid’ and some antihypertensive agents may attenuate acutely the hypotensive effect of the latter, due partly to indomethacin’s inhibition of prostaglandin synthesis. Therefore, caution should be exercised when considering the addition of ‘Indocid’ to the regimen of a patient taking any of the following antihypertensive agents: alpha-adrenergic blocking agents, ACE inhibitors, beta-adrenergic blocking agents, diuretics, hydralazine, or losartan (an angiotensin II receptor antagonist)..

Phenylpropanolamine', hypertensive crises have been reported due to oral phenylpropanolamine alone and, rarely, to phenylpropanolamine given with ‘Indocid’. This additive effect is probably due partly to indomethacin’s inhibition of prostaglandin synthesis. Caution should be exercised when ‘Indocid’ and phenylpropanolamine are administered concomitantly. Corticosteroids' the risk of gastro-intestinal bleeding and ulceration associated with NSAIDs is increased when used with corticosteroids.

Mifepristone: NSAIDs and aspirin should be avoided until at least 8 to 12 days after administration of mifepristone.

Quinolones Antibiotics: there have been reports that 4-quinolones may induce convulsions in patients with or without a history of convulsions; taking NSAIDs at the same time may also induce them.

4.6 Pregnancy and lactation

Use in pregnancy: ‘Indocid’ should be used during the first two trimesters of pregnancy only if the potential benefit justifies the potential risk to the foetus.

The known effects of indomethacin and other drugs of this class on the human foetus during the third trimester of pregnancy include: constriction of the ductus arteriosus prenatally, tricuspid incompetence, and pulmonary hypertension; non-closure of the ductus arterisosus postnatally which may be resistant to medical management; myocardial degenerative changes, platelet dysfunction with resultant bleeding, intracranial bleeding, renal dysfunction or failure, renal injury/dysgenesis which may result in prolonged or permanent renal failure, oligohydramnios, gastro-intestinal bleeding or perforation and increased risk of necrotising enterocolitis. Use of ‘Indocid’ during the third trimester of pregnancy is not recommended.

Use in breast-feeding: administration of ‘Indocid’ is not recommended in breast-feeding mothers. Indomethacin is excreted in breast milk.

4.7 Effects on ability to drive and use machines

Patients should be warned that they may experience dizziness, drowsiness, visual disturbances or headaches and if they do, should not drive or undertake activities requiring alertness.

4.8 Undesirable effects

CNS reactions - headaches, dizziness, light-headedness, depression, vertigo, and fatigue (including malaise and listlessness). Reactions reported infrequently include mental confusion, anxiety, syncope, drowsiness, convulsions, coma, peripheral neuropathy, muscle weakness, involuntary muscle movements, insomnia, psychiatric disturbances such as hallucinations, depersonalisation; and, rarely, paraesthesia, dysarthria, aggravation of epilepsy and Parkinsonism. These are often transient and disappear frequently with continued treatment or with reduced dosage. However, occasionally, severe reactions require stopping therapy.

Gastrointestinal - the more frequent reactions are nausea, anorexia, vomiting, epigastric distress, abdominal pain, constipation, and diarrhoea. Others which may develop are ulceration - single or multiple - of oesophagus, stomach, duodenum or small or large intestine, including perforation and haemorrhage with a few fatalities having been reported; gastro-intestinal tract bleeding without obvious ulcer formation; and increased abdominal pain when used in patients with pre-existing ulcerative colitis. Reactions occurring infrequently are stomatitis; gastritis; flatulence; bleeding from the sigmoid colon - occult or from a diverticulum - and perforation of pre-existing sigmoid lesions (diverticula, carcinoma). Rarely, intestinal strictures (diaphragms) and intestinal ulceration followed by stenosis and obstruction has been reported. With suppositories, tenesmus and irritation of the rectal mucosa have occasionally been reported. Other gastro-intestinal side effects which may or may not be caused by indomethacin include: ulcerative colitis and regional ileitis.

Hepatic - rarely, hepatitis and jaundice. (Some fatalities reported.)

Cardiovascular/Renal - oedema, increased blood pressure, tachycardia, chest pain, arrhythmia, palpitation, hypotension, congestive heart failure, blood urea elevation, and haematuria (all infrequent).

Dermatological/Hypersensitivity - pruritus, urticaria, angioneurotic oedema, angiitis, erythema nodosum, skin rash and photosensitivity, exfoliative dermatitis, Stevens-Johnson syndrome, erythema multiforme, toxic epidermal necrolysis, loss of hair, rapid fall in blood pressure resembling a shock-like state, acute anaphylaxis, acute respiratory distress including sudden dyspnoea, asthma and pulmonary oedema (all infrequent). Bronchospasm may be precipitated in patients suffering from, or with a history of, bronchial asthma or allergic disease.

Haematological - infrequently, blood dyscrasias may occur, including leucopenia, petechiae or ecchymosis, purpura, aplastic and haemolytic anaemia, agranulocytosis, bone-marrow depression, disseminated intravascular coagulation, and particularly thrombocytopenia. Because some patients may develop anaemia secondary to obvious or occult gastro-intestinal bleeding, appropriate blood determinations are recommended.

Ocular - infrequently, blurred vision, diplopia, and orbital and peri-orbital pain. Corneal deposits and retinal disturbances, including those of the macula, have been reported in patients with rheumatoid arthritis on prolonged therapy, but similar changes may also be expected in patients with rheumatoid arthritis who have not received indomethacin.

Aural - tinnitus, hearing disturbances (rarely deafness).

Genito-urinary - proteinuria, nephrotic syndrome, interstitial nephritis, and renal insufficiency including renal failure (all rare).

Miscellaneous - vaginal bleeding, hyperglycaemia, glycosuria, hyperkalaemia, flushing and sweating, epistaxis, breast changes including enlargement and tenderness, gynaecomastia, and ulcerative stomatitis (all rare).

The following adverse reactions have been associated with use of ‘Indocid’ Suppositories: tenesmus; proctitis; rectal bleeding, burning, pain, discomfort, and itching.

Laboratory tests

Borderline elevations of one or more liver tests may occur, and significant elevations of ALT (SGPT) or AST (SGOT) have been seen in less than 1% of patients receiving therapy with non-steroidal anti-inflammatory drugs in controlled clinical trials. If abnormal liver tests persist or worsen, if clinical signs and symptoms consistent with liver disease develop, or if systemic manifestations such as rash or eosinophilia occur, ‘Indocid’ should be stopped.

False-negative results in the dexamethasone suppression test (DST) in patients being treated with ‘Indocid’ have been reported. Thus, results of this test should be used with caution in these patients.

4.9 Overdose

The following symptoms may be observed following overdosage: nausea, vomiting, intense headache, dizziness, mental confusion, disorientation, or lethargy. There have been reports of paraesthesia, numbness, and convulsions.

Treatment is symptomatic and supportive. The stomach should be emptied as quickly as possible if the ingestion is recent and correction of severe electrolyte abnormalities may need to be considered.

If vomiting has not occurred spontaneously, the patient should be induced to vomit with syrup of ipecac. If the patient is unable to vomit, gastric lavage should be performed. Once the stomach has been emptied, 25 or 50 g of activated charcoal may be given. Depending on the condition of the patient, close medical observation and nursing care may be required. The patient should be followed for several days because gastro-intestinal ulceration and haemorrhage have been reported as adverse reactions of indomethacin. Use of antacids may be helpful.

The plasma elimination of indomethacin is biphasic with the half-life of the terminal plasma half-life phase between 2.6 and 11.2 hours.

5 PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Indomethacin has anti-inflammatory, antipyretic, and analgesic effects, it is an inhibitor of prostaglandin synthetase.

5.2 Pharmacokinetic properties

Indomethacin is rapidly and almost completely absorbed on oral administration, and peak plasma levels are reached in 'A to 2 hours. Absorption is slowed but remains virtually complete when taken with food. About 90% is bound to plasma proteins. It appears to undergo enterohepatic cycling. It is metabolised partly by O-demthylation, partly by N-deacylation, and unchanged drug and metabolites are partly conjugated with glucoronic acid, in man, it is excreted unchanged and as it metabolites in both urine and faeces.

5.3 Preclinical safety data

No relevant information.

6 PHARMACEUTICAL PARTICULARS

6.1    List of excipients

Butylhydroxyanisole, butylhydroxytoluene, ethylenediamine-tetracrotic acid, glycerol, polyethylene glycol 8000, macrogol 4000 , and purified water.

6.2 Incompatibilities

None known.

6.3    Shelf life

36 months.

6.4    Special precautions for storage

Do not store above 25°C. Keep in original package.

6.5    Nature and contents of container

10 capsules packed in polyvinylchloride (pvc) blister, laminate strip packaging.

6.6    Special precautions for disposal

None.

7.    Marketing Authorisation Holder

Aspen Pharma Trading Limited 3016 Lake Drive,

Citywest Business Campus,

Dublin 24,

Ireland.

8    MARKETING AUTHORISATION NUMBER(S)

PL 39699/015

9    DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

Licence first granted 13 October 1981.

10    DATE OF REVISION OF THE TEXT

29/10/2014