Ranitidine Effervescent Tablets 150mg
SUMMARY OF PRODUCT CHARACTERISTICS
1 NAME OF THE MEDICINAL PRODUCT
Ranitidine Effervescent Tablets 150mg
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
Each effervescent tablet contains 168 mg Ranitidine hydrochloride, equivalent to 150 mg Ranitidine.
Excipients with known effect:
Each Ranitidine 150 mg effervescent tablet contains 438 mg lactose monohydrate and 120 mg sodium.
For the full list of excipients, see section 6.1.
3. PHARMACEUTICAL FORM
Effervescent tablet.
Yellow-white to light-yellow cylindrical effervescent tablets with bevelled edges.
4 CLINICAL PARTICULARS
4.1 Therapeutic indications
For the treatment of diseases of the upper gastro-intestinal tract, in which a reduction of gastric acid secretion is indicated:
Adults
• Duodenal ulcer
• Benign gastric ulcer
• Long-term treatment of duodenal ulcers to prevent their recurrence. Long-term treatment is indicated in patients with a history of recurrent ulcer
• Reflux oesophagitis
• Zollinger-Ellison syndrome.
Ranitidine is not indicated for the treatment of minor gastrointestinal complaints, such as a nervous stomach.
Children (3 to 18 years)
• Short term treatment of peptic ulcer
• Treatment of gastro-oesophageal reflux, including reflux oesophagitis and symptomatic relief of gastro-oesophageal reflux disease.
4.2 Posology and method of administration
Posology
For adults with normal renal function, the following dosing guidelines apply:
DUODENAL AND BENIGN GASTRIC ULCERS:
2 effervescent tablets of Ranitidine 150 mg (= 300 mg Ranitidine) after supper or at bedtime. Alternatively, 1 effervescent tablet of Ranitidine 150 mg twice daily, taken in the morning and evening.
The therapy should last for four weeks. In the occasional patient in whom the ulcer is not fully healed after four weeks treatment, the treatment should be continued for a further four weeks at the same dose.
DUODENAL ULCERS LONG TERM TREATMENT
Patients, who have responded to such short-term treatment, and only those with a history of recurrent ulcer, may if necessary continue treatment for up to 12 months with 1 effervescent tablet of Ranitidine 150 mg daily at bedtime, for prophylaxis of recurrence. Patients should undergo regular endoscopic examination.
FOR REFLUX OESOPHAGITIS, 2 effervescent tablets of Ranitidine 150 mg (= 300 mg Ranitidine) after supper or at bedtime. Alternatively 1 effervescent tablet Ranitidine 150 mg twice daily (if necessary 4 times daily = 600 mg Ranitidine/day), taken in the morning and evening, for up to 8 weeks (12 weeks if necessary)
PATIENTS WITH VERY HIGH GASTRIC ACID SECRETION, E.G. ZOLLINGER-ELLISON SYNDROME, should initially receive treatment with 1 Ranitidine effervescent tablet 150 mg three times daily (= 450 mg Ranitidine daily). If necessary, the dose may be increased to 4-6 Ranitidine effervescent tablets 150 mg daily (=600-900 mg Ranitidine daily).
Patients may be stabilised on higher doses if measurement of gastric acid secretion demonstrates this to be necessary. Daily doses of up to 6 g Ranitidine have been given.
Doses may be administered irrespective of mealtimes.
Children 12 years and over
For children 12 years and over the adult dosage is given.
Children from 3 to 11 years and over 30 kg of weight
See section 5.2 Pharmacokinetic Properties (Special Patient Populations)
Peptic Ulcer Acute Treatment
The recommended oral dose for the treatment of peptic ulcer in children is 4 mg/kg/day to 8 mg/kg/day administered as two divided doses to a maximum of 300 mg ranitidine
per day for a duration of 4 weeks. For those patients with incomplete healing, another 4 weeks of therapy is indicated, as healing usually occurs after eight weeks of treatment.
Gastro-Oesophageal Reflux
The recommended oral dose for the treatment of gastro-oesophageal reflux in children is 5 mg/kg/day to 10 mg/kg/day administered as two divided doses in a maximum dose of 600 mg (the maximum dose is likely to apply to heavier children or adolescents with severe symptoms).
Neonates
Safety and efficacy in new-born patients has not been established.
DOSAGE GUIDE FOR PATIENTS WITH RENAL IMPAIRMENT
Depending on the creatinine clearance (ml/min) or serum creatinine level (mg/100 ml),
the following dosages are recommended:
|
Creatinine clearance (ml/min) |
Serum creatinine (approx.)* (mg/100 ml) |
Daily dose (oral) |
|
Up to 30 |
Over 2.6 |
150 mg Ranitidine |
|
Over 30 |
Under 2.6 |
300 mg Ranitidine |
* The serum creatinine values are guidelines, which do not represent the same level of impairment for all patients with reduced kidney function. This is especially the case in elderly patients in whom there is an overestimation of kidney function through the serum creatinine concentration.
The following formula can be used to estimate creatinine clearance from the measured serum creatinine (mg/100 ml), age (in years) and body weight (in kg). For women, the result needs to be multiplied by the factor 0.85.
Creatinine clearance (ml/min)= (140-age) x body weight
72 x serum creatinine
Ranitidine is dialysable. Haemodialysis reduces blood Ranitidine levels. Thus, dialysis patients should receive the above dose of Ranitidine after completion of dialysis.
Method of administration
Dissolve an effervescent tablet in a glass of water. Do not break the effervescent tablet. Wait until the effervescent tablet has been completely dissolved and drink the solution directly.
4.3 Contraindications
Hypersensitivity to the active substance or to any component of the excipients listed in section 6.1.
4.4
Special warnings and precautions for use
The possibility of malignancy should be excluded before commencement of therapy in patients with gastric ulcer as treatment with ranitidine may mask symptoms of gastric carcinoma.
Ranitidine is excreted via the kidney and so plasma levels of the drug are increased in patients with severe renal impairment. The dosage should be adjusted as detailed above section 4.2 under Dosage guide for patients with renal impairment.
Rare clinical reports suggest that ranitidine may precipitate acute porphyric attacks. Ranitidine should therefore be avoided in patients with a history of acute porphyria.
In patients such as the elderly, persons with chronic lung disease, diabetes or the immunocompromised, there may be an increased risk of developing community acquired pneumonia.
A large epidemiological study showed an increased risk of developing community acquired pneumonia in current users of ranitidine alone (H2 receptor antagonist) versus those who had stopped treatment, with an observed adjusted relative risk increase of 1,82 (95% CI, 1,26-2,64).
Patients with peptic ulcers should be tested for the presence of H. pylori. If they are found positive an adequate eradication regimen should be given.
Caution should be observed in patients with severe hepatic dysfunction since ranitidine is metabolised in liver.
Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.
This product contains 120 mg sodium per dose. To be taken into consideration by patients on controlled sodium diet.
4.5 Interaction with other medicinal products and other forms of interaction
Ranitidine has the potential to affect the absorption, metabolism or renal excretion of other drugs. The altered pharmacokinetics may necessitate dosage adjustment of the affected drug or discontinuation of treatment.
Interactions occur by several mechanisms including:
1) Inhibition of cytochrome P450-linked mixed function oxygenase system: Ranitidine at usual therapeutic doses does not potentiate the actions of drugs which are inactivated by this enzyme system such as diazepam, lidocaine, phenytoin, propranolol and theophylline.
There have been reports of altered prothrombin time with coumarin anticoagulants (e.g. warfarin). Due to the narrow therapeutic index, close monitoring of increased or decreased prothrombin time is recommended during concurrent treatment with ranitidine.
2) Competition for renal tubular secretion:
Since ranitidine is partially eliminated by the cationic system, it may affect the clearance of other drugs eliminated by this route. High doses of ranitidine (e.g. such as those used in the treatment of Zollinger-Ellison syndrome) may reduce the
excretion of procainamide and N-acetylprocainamide resulting in increased plasma levels of these drugs.
3) Alteration of gastric pH:
The bioavailability of certain drugs may be affected. This can result in either an increase in absorption (e.g. triazolam, midazolam, glipizide) or a decrease in absorption (e.g. ketoconazole, atazanavir, delaviridine, gefitnib).
There is no evidence of an interaction between ranitidine and amoxicillin and metronidazole.
If high doses (2 g) of sucralfate are co-administered with ranitidine the absorption of the latter may be reduced. This effect is not seen if sucralfate is taken after an interval of 2 h.
Ranitidine may increase the effects of alcohol.
4.6 Fertility, pregnancy and lactation
Pregnancy
Ranitidine crosses the placenta. Like other drugs ranitidine should only be used during pregnancy if considered essential.
Lactation:
Ranitidine is excreted in human breast milk. Like other drugs ranitidine should only be used during nursing if considered essential.
4.7 Effects on ability to drive and use machines
There are side effects reported when using Ranitidine effervescent tablets.
The effects of small amounts of alcohol may increase when taken together with Ranitidine effervescent tablets (see section 4.5). Under these circumstances the ability to react as well as the power of judgment may be reduced, thus impairing the ability to drive and the ability to operate machinery.
4.8 Undesirable effects
The following convention has been utilised for the classification of undesirable effects: very common (>1/10), common (>1/100 to <1/10), uncommon (>1/1000 to <1/100), rare (>1/10,000 to <1/1000), very rare (<1/10,000), not known (cannot be estimated from available data)
Adverse event frequencies have been estimated from spontaneous reports from postmarketing data.
Blood and lymphatic system disorders Very rare
Blood count changes (leucopenia, thrombocytopenia). These are usually reversible. Agranulocytosis or pancytopenia, sometimes with marrow hypoplasia or marrow aplasia.
Immune system disorders Rare:
Hypersensitivity reactions (urticaria, angioneurotic oedema, fever, bronchospasm, hypotension and chest pain)
Very rare
Anaphylactic shock. These events have been reported after a single dose.
Psychiatric disorders
Very rare
Reversible mental confusion, depression and hallucinations.
These have been reported predominantly in severely ill and elderly patients.
Nervous system disorders Uncommon:
Fatigue
Very rare
Headache (sometimes severe), dizziness and reversible involuntary movement disorders.
Eye disorders
Very rare
Reversible blurred vision. There have been reports of blurred vision, which is suggestive of a change in accommodation.
Cardiac disorders
Very rare
As with other H2-receptor antagonists bradycardia and AV-block
Vascular disorders Very Rare:
Vasculitis
Respiratory, thoracic and mediastinal disorders
Not known
Pneumonia (see section 4.4)
Gastrointestinal disorders
Uncommon
Abdominal pain, diarrhoea, constipation, nausea (these symptoms mostly improved during continued treatment)
Very rare Acute pancreatitis
Hepatobiliary disorders
Rare
Transient and reversible changes in liver function tests
Very rare
Hepatitis (hepatocellular, hepatocanalicular or mixed) with or without jaundice,these were usually reversible.
Skin and subcutaneous tissue disorders Rare
Skin rash, pruritis.
Very rare
Erythema multiforme,alopecia
Musculoskeletal and connective tissue disorders
Very rare
Musculoskeletal symptoms such as arthralgia and myalgia
Renal and urinary disorders
Rare
Elevation of plasma creatinine (usually slight; normalised during continued treatment)
Very rare
Acute interstitial nephritis
Reproductive system and breast disorders
Very rare
Reversible impotence, breast symptoms and breast conditions (such as gynaecomastia and galactorrhoea)
Paediatric population
The safety of ranitidine has been assessed in children aged 0 to 16 years with acid-related disease and was generally well tolerated with an adverse event profile resembling that in adults. There are limited long term safety data available, in particular regarding growth and development.
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 at: www.mhra.gov.uk/yellowcard
4.9 Overdose
Symptoms and signs
Ranitidine is very specific in action and no particular problems are expected following overdosage with ranitidine formulations.
Treatment
Symptomatic and supportive therapy should be given as appropriate.
5 PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: H2-receptor antagonist, ATC-code: A02B A02.
Ranitidine is a competitive histamine H2 -receptor antagonist. It inhibits basal gastric secretion and gastric secretion stimulated e.g. by histamine, pentagastrin and food. Ranitidine decreases both the acid content and also to a smaller extent the pepsin content and volume of the gastric juice.
In two studies using therapeutic doses of ranitidine 150 mg twice daily, gastric acid secretion was reduced by a mean of 63% and 69% respectively over 24 hours, with reductions of 73% and 90% respectively in nocturnal acid secretion. In two studies using the dosage recommended for prophylaxis of recurrence (150 mg nocte) Ranitidine produced mean reductions in gastric acid secretion of 42% and 69% respectively within 24 hours.
The gastric acid secretion was reduced by a mean of 50 to 60% within 24 hours after administration of therapeutic doses of 300 mg Ranitidine nocte, while the nocturnal acid secretion was reduced by approximately 90%.
5.2 Pharmacokinetic properties
Absorption:
Ranitidine is rapidly absorbed after oral administration and attains peak blood concentrations after a mean of 1.25 - 3 hours. The mean bioavailability of Ranitidine in tablet form is approx. 50 % but inter-individual variation in bioavailability is wide, being quoted as 28 - 76 % in one study.
Distribution:
Plasma protein binding is approx. 15%. The apparent distribution volume in adults is 1.2-1.8 l/kg and in children 2.5 l/kg.
After oral ingestion of 150 mg Ranitidine as tablet, peak plasma levels of around 400 ng/ml were attained, with wide-individual variation. At twelve hours, mean plasma levels were still approx. 40 ng/ml. After administration of 300 mg Ranitidine, peak plasma levels of approx. 700-800 ng/ml were attained.
The plasma concentration required for 50% inhibition of acid secretion in adults averaged 73-165 ng/ml in a number of studies.
To a very small extent, Ranitidine passes into the cerebrospinal fluid.
Biotransformation:
Ranitidine is metabolised in the liver to Ranitidine-N-oxide, N-Desmethyl Ranitidine, Ranitidine-S-oxide and the furane acid analogue.
Elimination:
Measurements of total clearance yielded mean values of 570-710 ml/min in
2
adults. In children and adolescents a total clearance of almost 800 ml/min/1.73 m was found, with a wide degree of scatter.
After oral administration, Ranitidine is excreted within 24 hours via the kidneys to approx. 30% as unchanged Ranitidine, up to 6% as N-oxide, to a small degree
in demethylised and in S-oxidised form, and as furane acid analogue. In patients with sound kidneys, renal excretion is effected predominantly by tubular secretion with a renal clearance of about 490-520 ml/min. Additionally, Ranitidine is excreted via the bile.
Special patient population:
Patients with renal impairment
After oral intake, mean elimination half-life in patients with sound kidneys is 2.33 hours. In patients with renal insufficiency, the half-life is prolonged two to threefold.
Children (3 years and above)
Limited pharmacokinetic data have shown that there are no significant differences in half-life (range for children 3 years and above: 1.7 - 2.2 h) and plasma clearance (range for children 3 years and above: 9 - 22 ml/min/kg) between children and healthy adults receiving oral ranitidine when correction is made for body weight.
5.3 Preclinical safety data
Preclinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential, and toxicity to reproduction.
6 PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Tartaric acid,
Sodium hydrogen carbonate,
Lactose monohydrate,
Povidone,
Riboflavin 5-phosphate sodium (E101),
Simethicone emulsion, (contains Simethicone, methylcellulose, sorbic acid and purified water)
Sodium cyclamate,
Saccharin sodium,
Lemon flavour H&R 290252 (contains citral, citronella oil, coriander oil, lime and acacia)
Macrogol 6000 Sodium hydroxide.
6.2 Incompatibilities
None known
6.3 Shelf life
3 years.
6.4 Special precautions for storage
Do not store above 30°C. Keep the container tightly closed.
6.5 Nature and contents of container
Polypropylene container with LDPE cap. A quantity of desiccant (silicage zeolitel) is incorporated into the cap.
Pack sizes: 10, 20, 30, 50, 60, 90 or 100 effervescent tablets.
6.6 Special precautions for disposal
No special requirements.
7 MARKETING AUTHORISATION HOLDER
Ratiopharm GmbH Graf-Arco-Str. 3 89079 Ulm Germany
8 MARKETING AUTHORISATION NUMBER(S)
PL 15773/0066
9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
02/04/2006
10 DATE OF REVISION OF THE TEXT
27/03/2014