Medine.co.uk

Misofen 50mg/200microgram Modified Release Tablets

SUMMARY OF PRODUCT CHARACTERISTICS

1 NAME OF THE MEDICINAL PRODUCT

Misofen 50mg/200microgram modified release tablets

2 QUALITATIVE AND QUANTITATIVE COMPOSITION

Each tablet consists of a gastro-resistant core containing 50 mg diclofenac sodium surrounded by an outer mantle containing 200 micrograms misoprostol.

Excipient(s):

Each tablet contains 20.0 mg lactose monohydrate.

For a full list of excipients, see section 6.1.

3 PHARMACEUTICAL FORM

Modified Release Tablet

White circular, biconvex uncoated tablets plain one side and embossed with “DM2” on the other side.

4    CLINICAL PARTICULARS

4.1    Therapeutic indications

Misofen tablets are indicated for patients who require the non-steroidal antiinflammatory drug diclofenac together with misoprostol.

The diclofenac component of Misofen Tablets is indicated for the symptomatic treatment of osteoarthritis and rheumatoid arthritis. The misoprostol component of Misofen Tablets is indicated for patients with a special need for the prophylaxis of NSAID-induced gastric and duodenal ulceration.

4.2 Posology and method of administration

Adults

One tablet to be taken with food, two or three times daily. Tablets should be swallowed whole, not chewed.

Elderly/Renal and Hepatic Impairment

No adjustment of dosage is necessary in the elderly or in patients with hepatic impairment or mild to moderate renal impairment as pharmacokinetics are not altered to any clinically relevant extent. Nevertheless, elderly patients and patients with renal or hepatic impairment should be closely monitored (see section 4.4 and section 4.8).

Children (under 18 years)

The safety and efficacy of Misofen Tablets in children has not been established.

Undesirable effects may be minimised by using the lowest effective dose for the shortest duration necessary to control symptoms (see section 4.4).

4.3 Contraindications

Misofen Tablets are contraindicated in:

-    Patients with active peptic ulcer/haemorrhage or perforation or who have active GI bleeding or other active bleedings e.g. cerebrovascular bleedings.

-    Pregnant women and in women planning a pregnancy.

-    Patients with a known hypersensitivity to diclofenac, aspirin, other NSAIDs, misoprostol, other prostaglandins, or any other ingredient of the product.

-    Patients in whom, attacks of asthma, urticaria or acute rhinitis are precipitated by aspirin or other non-steroidal anti-inflammatory agents.

-    Treatment of peri-operative pain in the setting of coronary artery bypass graft (CABG) surgery.

-    Patients with severe renal and hepatic failure.

-    Patients with established congestive heart failure (NYHA II-IV), ischemic heart disease,peripheral arterial disease and/or cerebrovascular disease

4.4 Special warnings and precautions for use

Warnings

The use of diclofenac/misoprostol with concomitant NSAIDs including COX-2 inhibitors should be avoided.

Use in pre-menopausal women (see also section 4.3)

Misofen Tablets should not be used in pre-menopausal women unless they use effective contraception and have been advised of the risks of taking the product if pregnant (see section 4.6). The label will state: 'Not for use in pre-menopausal women unless using effective contraception'.

Precautions

Undesirable effects may be minimised by using the lowest effective dose for the shortest duration necessary to control symptoms (see section 4.2, and GI and cardiovascular risks below).

Renal/Cardiac/Hepatic

In patients with renal, cardiac or hepatic impairment and in the elderly, caution is required since the use of NSAIDs may result in deterioration of renal function. In the following conditions, Misofen Tablets should be used only in exceptional circumstances and with close clinical monitoring: advanced cardiac failure, advanced kidney failure, advanced liver disease, severe dehydration. Diclofenac metabolites are eliminated primarily by the kidneys (see section 5.2). The extent to which the metabolites may accumulate in patients with renal failure has not been studied. As with other NSAIDs, metabolites of which are excreted by the kidney, patients with significantly impaired renal function should be more closely monitored.

In rare cases, NSAIDs, including diclofenac/misoprostol, may cause interstitial nephritis, glomerulitis, papillary necrosis and the nephrotic syndrome. NSAIDs inhibit the synthesis of renal prostaglandin which plays a supportive role in the maintenance of renal perfusion in patients whose renal blood flow and blood volume are decreased. In these patients, administration of an NSAID may precipitate overt renal decompensation, which is typically followed by recovery to pretreatment state upon discontinuation of NSAID therapy. Patients at greatest risk of such a reaction are those with congestive heart failure, liver cirrhosis, nephrotic syndrome and overt renal disease.

Such patients should be carefully monitored while receiving NSAID therapy.

Appropriate monitoring and advice are required for patients with a history of hypertension and/or mild to moderate congestive heart failure as fluid retention and oedema have been reported in association with NSAID therapy.

As with all NSAIDS, diclofenac/misoprostol can lead to the onset of new hypertension or worsening of pre-existing hypertension, either of which may contribute to the increased incidence of cardiovascular events. NSAIDs, including diclofenac/misoprostol, should be used with caution in patients with hypertension. Blood pressure should be monitored closely during the initiation of therapy with diclofenac/misoprostol and throughout the course of therapy.

Patients with uncontrolled hypertension, congestive heart failure, established ischaemic heart disease, peripheral arterial disease, and/or cerebrovascular disease should only be treated with diclofenac after careful consideration. Patients with significant risk factors for cardiovascular events (eg. hypertension, hyperlipidaemia, diabetes mellitus, smoking) should only be treated with diclofenac after careful consideration. As the cardiovascular risks of diclofenac may increase with dose and duration of exposure, the shortest duration possible and the lowest effective daily dose may be used. The patient’s need for symptomatic relief and response to therapy should be reevaluated periodically.

Clinical trial and epidemiological data suggest that use of diclofenac, particularly at high dose (150mg daily) and in long term treatment may be associated with a small increased risk of serious arterial thrombotic events (for example myocardial infarction or stroke).

Physicians and patients should remain alert for the development of such events, even in the absence of previous cardiovascular symptoms. Patients should be informed about the signs and/or symptoms of serious cardiovascular toxicity and the steps to take if they occur (see section 4.3).

Blood system/Gastrointestinal

NSAIDs, including diclofenac/misoprostol, can cause serious gastrointestinal (GI) adverse events including inflammation, bleeding, ulceration, and perforation of the stomach, small intestine, or large intestine, which can be fatal. When GI bleeding or ulceration occurs in patients receiving diclofenac/misoprostol, the treatment should be withdrawn. These events can occur at any time during treatment, with or without warning symptoms or in patients with a previous history of serious GI events.

Patients most at risk of developing these types of GI complications with NSAIDs are those treated at higher doses, the elderly, patients with cardiovascular disease, patients using concomitant aspirin, or patients with a prior history of, or active, gastrointestinal disease, such as ulceration, GI bleeding or inflammatory conditions.

Therefore, diclofenac/misoprostol should be used with caution in these patients and commence on treatment at the lowest dose available (see section 4.3).

Patients with a history of GI toxicity, particularly when elderly, should report any unusual abdominal symptoms (especially GI bleeding) particularly in the initial stages of treatment. Caution should be advised in patients receiving concomitant medicines which could increase the risk of ulceration or bleeding, such as oral corticosteroids, anticoagulants such as warfarin, selective serotonin-reuptake inhibitors or anti-platelet agents such as aspirin (see section 4.5).

Misofen Tablets in common with other NSAIDs, may decrease platelet aggregation and prolong bleeding time. Extra supervision is recommended in haematopoietic disorders or in conditions with defective coagulation or in patients with a history of cerebrovascular bleeding.

Caution is required in patients suffering from ulcerative colitis or Crohn's Disease as these conditions may be exacerbated (see section 4.8).

Care should be taken in elderly patients and in patients treated with corticosteroids, other NSAIDs, or anti-coagulants (see section 4.5).

Skin Reactions

Serious skin reactions, some of them fatal, including exfoliative dermatitis, Stevens-Johnson syndrome, and toxic epidermal necrolysis, have been reported very rarely in association with the use of NSAIDs, including diclofenac/misoprostol (see section 4.8). Patients appear to be at highest risk for these events early in the course of therapy, the onset of the event occurring in the majority of cases within the first month of treatment. Diclofenac/misoprostol should be discontinued at the first appearance of skin rash, mucosal lesions, or any other sign of hypersensitivity.

Hypersensitivity

NSAIDs may precipitate bronchospasm in patients suffering from, or with a history of bronchial asthma or allergic disease.

Long-term treatment

All patients who are receiving long-term treatment with NSAIDs should be monitored as a precautionary measure (e.g. renal, hepatic function and blood counts). During long-term, high dose treatment with analgesic/anti-inflammatory drugs, headaches can occur which must not be treated with higher doses of the medicinal product.

•    Misofen Tablets may mask fever and thus an underlying infection.

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

4.5 Interaction with other medicinal products and other forms of interaction

NSAIDs may attenuate the natriuretic efficacy of diuretics due to inhibition of intrarenal synthesis of prostaglandins. Concomitant treatment with potassium-sparing diuretics may be associated with increased serum potassium levels; hence serum potassium should be monitored.

Because of their effect on renal prostaglandins, cyclo-oxygenase inhibitors such as diclofenac can increase the nephrotoxicity of ciclosporin. There is a possible increased risk of nephrotoxicity when NSAIDs are given with tacrolimus.

Steady state plasma lithium and digoxin levels may be increased and ketoconazole levels may be decreased.

Pharmacodynamic studies with diclofenac have shown no potentiation of oral hypoglycaemic and anticoagulant drugs. However, as interactions have been reported with other NSAIDs, caution and adequate monitoring are, nevertheless advised (see statement on platelet aggregation in Precautions).

Because of decreased platelet aggregation caution is advised when using Misofen Tablets with anti-coagulants. NSAIDs may enhance the effects of anti-coagulants, such as warfarin, antiplatelet agents, such as aspirin, and serotonin re-uptake inhibitors (SSRIs) thereby increasing the risk of gastrointestinal bleeding (see section 4.4).

Cases of hypo and hyperglycaemia have been reported when diclofenac was associated with antidiabetic agents.

Caution is advised when methotrexate is administered concurrently with NSAIDs because of possible enhancement of its toxicity by the NSAID as a result of increase in methotrexate plasma levels.

Concomitant use with other NSAIDs or with corticosteroids may increase the frequency of gastrointestinal ulceration or bleeding and of side effects generally.

Anti-hypertensives including diuretics, angiotensin-converting enzyme (ACE) inhibitors and angiotensin II antagonists (AIIA): NSAIDs can reduce the efficacy of diuretics and other antihypertensive drugs.

In patients with impaired renal function (e.g. dehydrated patients or elderly patients with compromised renal function), the co-administration of an ACE inhibitor or an AIIA with a cyclo-oxygenase inhibitor can increase the deterioration of the renal function, including the possibility of acute renal failure, which is usually reversible. The occurrence of these interactions should be considered in patients taking diclofenac/misoprostol with an ACE inhibitor or an AIIA.

Antacids may delay the absorption of diclofenac. Magnesium-containing antacids have been shown to exacerbate misoprostol-associated diarrhoea.

Animal data indicate that NSAIDs can increase the risk of convulsions associated with quinolone antibiotics. Patients taking NSAIDs and quinolones may have an increased risk of developing convulsions.

NSAIDs should not be used for 8-12 days after mifepristone administration as NSAIDs can reduce the effect of mifepristone.

4.6 Fertility, pregnancy and lactation

Pregnancy

Misofen Tablets are contraindicated in pregnant women and in women planning a pregnancy because misoprostol induces uterine contractions and is associated with abortion, premature birth, and foetal death. Use of misoprostol has been associated with birth defects. Also diclofenac may cause premature closure of the ductus arteriosus.

Women of childbearing potential should not be started on diclofenac/misoprostol until pregnancy is excluded, and should be fully counselled on the importance of adequate contraception while undergoing treatment. If pregnancy is suspected, use of the product should be discontinued.

Lactation

Misoprostol is rapidly metabolised in the mother to misoprostol acid, which is biologically active and is excreted in breast milk. Diclofenac is excreted in breast milk in very small quantities. In general, the potential effects on the infant from any exposure to misoprostol and its metabolites via breast feeding are unknown. However, diarrhoea is a recognised side effect of misoprostol and could occur in infants of nursing mothers. Misofen Tablets should therefore not be administered to nursing mothers.

4.7 Effects on ability to drive and use machines

Patients who experience dizziness or other central nervous system disturbances while taking NSAIDs should refrain from driving or operating machinery.

4.8 Undesirable effects

In the table below the incidence of adverse drug reactions reported in controlled clinical studies where diclofenac/misoprostol was administered to more than 2000 patients are listed. Additionally, adverse drug reactions reported during postmarketing surveillance are whose frequency cannot be estimated from the available data, such as spontaneous reports, have been listed at frequency ‘unknown’. The most commonly observed adverse events are gastrointestinal in nature.

Organ System

Very

Common

(> 1/10)

Common

(>1/100 and <1/10)

Uncommon

(a 1/1,000 and <1/100)

Rare

(>1/10,000,

and

<1/1,000)

Frequency:

Unknown

(Post-marketing

experience)

Infections and infestations

Aseptic

meningitis1

Blood and lymphatic system disorders

Thrombo-

cytopaenia

Aplastic

anaemia,

agranulocytosis,

haemolytic

anaemia,

leucopenia

Immune system disorders

Anaphylactic

reaction

Hypersensitivity

Metabolism and

nutrition

disorders

Anorexia

Psychiatric

disorders

Insomnia

Psychotic

reaction,

disorientation,

depression,

anxiety,

nightmares,

mood change,

irritability

Nervous system disorders

Headache,

dizziness

Convulsions,

memory

disturbance,

drowsiness, tremor, taste disturbance, paraesthesia

Eyes disorders

Visual disturbances, blurred vision

Ear and

labyrinth

disorders

Tinnitus

Cardiac

disorders

Cardiac failure, palpitations

Vascular

disorders

Shock,

hypertension,

hypotension,

vasculitis

Respiratory, thoracic and mediastinal disorders

Asthma,

pneumonitis,

dyspnoea

Gastrointestinal

disorders

Abdominal

pain,

diarrhoea2 , nausea, dyspepsia

Gastritis,

vomiting,

flatulence,

eructation,

constipation,

peptic ulcer

Stomatitis

GI perforation3 , gastrointestinal bleeding3 , melaena, haematemesis, colitis, Crohn's disease, oesophageal disorder, mouth ulceration, glossitis, tongue odema, dry mouth

Hepato-biliary

disorders

Alanine

amino

transferase

increased

Hepatitis,

jaundice

Hepatitis

fulminant,

aspartate

aminotransferase

increased, blood

bilirubin

increased

Skin and subcutaneous tissue disorders

Erythema

multiforme,

rash,

Purpura,

urticaria

Angioedema

Toxic epidermal necrolysis4 , Stevens-Johnson

pruritus

syndrome4 ,

dermatitis

exfoliative4 ,

dermatitis

bullous, Henoch

Schonlein

purpura,

mucocutaneous

rash, rash

vesicular,

photosensitivity

reaction,

alopecia,

urticaria

Renal and

urinary

disorders

Renal failure,

acute renal

failure, renal

papillary

necrosis,

nephritis

interstitial,

nephrotic

syndrome,

proteinuria,

haematuria

Pregnancy, puerperium and perinatal conditions

Intra-uterine

death, uterine

rupture,

incomplete

abortion,

premature baby,

anaphylactoid

syndrome of

pregnancy,

retained placenta

or membranes,

uterine

contractions

abnormal

Reproductive system and breast disorders

Menorrhagia,

metrorrhagia,

vaginal

haemorrhage,

postmenopausal

haemorrhage

Uterine

haemorrhage

Congenital,

Birth defects

familial and

genetic

disorders

General disorders and administration site conditions

Oedema5 , chest pain, face oedema, fatigue, pyrexia, chills, inflammation

Investigations

Blood

alkaline

phosphatase

increased

Decreased

haemoglobin

Injury,

poisoning and

procedural

complications

Uterine

perforation

1    Symptoms of aseptic meningitis (stiff neck, headache, nausea, vomiting, fever or impaired consciousness) have been reported during treatment with NSAIDs. Patients suffering from autoimmune disease (e.g. lupus erythematosus, mixed connective tissue disorders) seem to be more susceptible.

2    Diarrhoea is usually mild to moderate and transient and can be minimised by taking Misofen Tablets with food and by avoiding the use of predominantly magnesium-containing antacids.

3    GI perforation or bleeding can sometimes be fatal, particularly in the elderly (see section 4.4).

4    Serious skin reactions, some of them fatal, have been reported very rarely (see section 4.4).

5    Especially in patients with hypertension or impaired renal function (see section 4.4).

Given the lack of precise and/or reliable denominator and numerator figures, the spontaneous adverse event reporting system through which post marketing safety data are collected does not allow for a medically meaningful frequency of occurrence of any undesirable effects.

With regard to the relative frequency of reporting of adverse reactions during post marketing surveillance, the undesirable effects at the gastrointestinal level were those received most frequently followed by cutaneous/hypersensitivity-type reactions, which is in agreement with the known side effects profile of the NSAIDs drug class.

Clinical trial and epidemiological data consistently point towards an increased risk of arterial thrombotic events (for example myocardial infarction or stroke) associated with the use of diclofenac, particularly at high dose (150mg daily) and in long term treatment. (see section 4.3 and 4.4 for Contraindications and Special warnings and special precautions for use).

4.9 Overdose

The toxic dose of Misofen Tablets has not been determined and there is no experience of overdosage. Intensification of the pharmacological effects may occur with overdosage. Management of acute poisoning with NSAIDs essentially consists of supportive and symptomatic measures. It is reasonable to take measures to reduce absorption of any recently consumed drug by forced emesis, gastric lavage or activated charcoal.

5 PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Anti-inflammatory and antirheumatic products, ATC code: M01BX

Misofen Tablets is a non-steroidal, anti-inflammatory drug, which is effective in treating the signs and symptoms of arthritic conditions.

This activity is due to the presence of diclofenac, which has been shown to have antiinflammatory and analgesic properties.

Misofen Tablets also contain the gastroduodenal mucosal protective component misoprostol, which is a synthetic prostaglandin E1 analogue that enhances several of the factors that maintain gastroduodenal mucosal integrity.

5.2 Pharmacokinetic properties

The pharmacokinetic profiles following oral administration of a single dose or multiple doses of diclofenac sodium and misoprostol administered as Misofen Tablets are similar to the profiles when the two drugs are administered as separate tablets. There are no pharmacokinetic interactions between the two components.

Diclofenac sodium is completely absorbed from the gastrointestinal (GI) tract after fasting oral administration. Only 50 % of the absorbed dose is systemically available due to first pass metabolism. Peak plasma levels are achieved in 2 hours (range 1-4 hours), when given as a single dose under fasting conditions.The area-under-the plasma-concentration curve (AUC) is dose proportional within the range of 25 mg to 150 mg.

The terminal half-life is approximately 2 hours. Clearance and volume of distribution are about 350 ml/min and 550 ml/kg, respectively. More than 99 % of diclofenac sodium is reversibly bound to human plasma albumin, and this has been shown not to be age dependent.

Diclofenac sodium is eliminated through metabolism and subsequent urinary and biliary excretion of the glucuronide and the sulfate conjugates of the metabolites. Approximately 65 % of the dose is excreted in the urine and 35 % in the bile. Less than 1 % of the parent drug is excreted unchanged.

Misoprostol is rapidly and extensively absorbed, and it undergoes rapid metabolism to its active metabolite, misoprostol acid, which is eliminated with an elimination t'A of about 30 minutes. No accumulation of misoprostol acid was found in multiple-dose studies, and plasma steady state was achieved within 2 days. The serum protein binding of misoprostol acid is less than 90 %. Approximately 70 % of the administered dose is excreted in the urine, mainly as biologically inactive metabolites.

5.3 Preclinical safety data

In co-administration studies in animals, the addition of misoprostol did not enhance the toxic effects of diclofenac. The combination was also shown not to be teratogenic or mutagenic. The individual components show no evidence of carcinogenic potential.

Misoprostol in multiples of the recommended therapeutic dose in animals has produced gastric mucosal hyperplasia. This characteristic response to E-series prostaglandins reverts to normal on discontinuation of the compound.

6    PHARMACEUTICAL PARTICULARS

6.1    List of excipients

Core:

lactose monohydrate microcrystalline cellulose maize starch povidone K-30 magnesium stearate purified talc

Mantle/Coat:

hypromellose

methylacrylic acid copolymer type C

purified talc

triethylcitrate

sodium starch glycolate

hydrogenated castor oil

microcrystalline cellulose

6.2 Incompatibilities

Not applicable.

6.3 Shelf life

2 years

6.4 Special precautions for storage

This medicine product does not require any special storage instructions.

6.5 Nature and contents of container

Misofen Tablets are presented in packs composed of OPA-ALU-PVC blisters with aluminium foil.

Pack size: 7, 10, 14, 15, 20, 28, 30, 50, 60, 90, 100, 140 tablets Not all pack sizes may be marketed.

6.6 Special precautions for disposal

No special requirements.

Any unused product or waste material should be disposed of in accordance with local requirements.

7    MARKETING AUTHORISATION HOLDER

Marketing Authorisation Holder:

Momingside Healthcare Limited 115 Narborough Road Leicester, LE3 0PA UK

8    MARKETING AUTHORISATION NUMBER(S)

PL 20117/0187

9    DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

10/10/2012

10    DATE OF REVISION OF THE TEXT

07/02/2014