1. Name Of The Medicinal Product
CLOPIXOL ACUPHASE
2. Qualitative And Quantitative Composition
Zuclopenthixol acetate 5.0% w/v equivalent to 4.526% w/v of zuclopenthixol base.
3. Pharmaceutical Form
Oily solution for deep intramuscular injection.
4. Clinical Particulars
4.1 Therapeutic Indications
For the initial treatment of acute psychoses including mania and exacerbation of chronic psychoses, particularly where a rapid onset of action, and a duration of effect of 2-3 days is desirable.
4.2 Posology And Method Of Administration
Adults
Dosage should be adjusted according to the severity of the patient's illness. Clopixol Acuphase is administered by deep intramuscular injection, into the upper outer buttock or lateral thigh.
The usual dosage is 50-150 mg (1-3 ml), repeated if necessary after 2 or 3 days. Some patients may need an additional injection between 1 and 2 days after the first injection.
Clopixol Acuphase is not intended for long-term use and duration of treatment should not be more than two weeks. The maximum accumulated dosage in a course should not exceed 400 mg and the number of injections should not exceed four.
Elderly
The dosage may need to be reduced in the elderly owing to reduced rates of metabolism and elimination. Maximum dosage per injection should be 100 mg.
Children
Not recommended for children
Reduced renal function
Clopixol-Acuphase can be given in usual doses to patients with reduced renal function. Where there is renal failure dosage should be reduced to half the normal dosage.
Reduced liver function
Use with caution in patients with hepatic disease (see section 4.4). Patients with compromised hepatic function should receive half the recommended dosages. Serum-level monitoring is advised.
Maintenance Therapy:
Clopixol Acuphase is not intended for long-term use.
A single injection of Clopixol Acuphase has an onset of sedative action shortly after injection and an antipsychotic action persisting for 2 to 3 days. In this period, maintenance treatment with tablets or a longer acting depot neuroleptic can be initiated. The possible side-effects of long-term maintenance treatment with a neuroleptic, including tardive dyskinesia, should be considered.
Maintenance treatment where required can be continued with Clopixol tablets, Clopixol injection or Clopixol conc. injection, according to the following guidelines:
1. Introduce Clopixol tablets at a dosage of 20-60 mg/day in divided doses, 2 to 3 days after the last injection of Clopixol Acuphase. If necessary increase the tablet dosage by 10-20 mg each day up to a maximum of 150 mg/day.
Or
2. Concomitantly with the last injection of Clopixol Acuphase, administer 200-400 mg of Clopixol injection or Clopixol Conc. injection by deep intramuscular injection and repeat the Clopixol injection or Clopixol Conc. injection at intervals of 2 to 4 weeks. Higher dosages or a shorter interval may be necessary.
Route of administration
deep intramuscular injection into the upper outer buttock or lateral thigh.
4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients (see section 6.1). Circulatory collapse, depressed level of consciousness due to any cause (e.g. intoxication with alcohol, barbiturates or opiates), coma.
4.4 Special Warnings And Precautions For Use
Like other neuroleptics zuclopenthixol acetate should be used with caution in patients with convulsive disorders or advanced hepatic, renal or cardiovascular disease.
Zuclopenthixol is not suitable for patients who do not tolerate oral neuroleptic drugs or for patients suffering from Parkinson's disease.
The possibility of development of neuroleptic malignant syndrome (hyperthermia, muscle rigidity, fluctuating consciousness, instability of the autonomous nervous system) exists with any neuroleptic. The risk is possibly greater with the more potent agents. Patients with pre-existing organic brain syndrome, mental retardation and opiate and alcohol abuse are over-represented among fatal cases.
Treatment:
Discontinuation of the neuroleptic. Symptomatic treatment and use of general supportive measures. Dantrolene and bromocriptine may be helpful. Symptoms may persist for more than a week after oral neuroleptics are discontinued and somewhat longer when associated with the depot forms of the drugs.
Like other neuroleptics, zuclopenthixol should be used with caution in patients with organic brain syndrome, convulsions or advanced hepatic disease.
Blood dyscrasias have been reported rarely. Blood counts should be carried out if a patient develops signs of persistent infection.
An approximately 3-fold increased risk of cerebrovascular adverse events has been seen in randomised placebo controlled clinical trials in the dementia population with some atypical antipsychotics. The mechanism for this increased risk is not known. An increased risk cannot be excluded for other antipsychotics or other patient populations.
Zuclopenthixol should be used with caution in patients with risk factors for stroke.
As with other drugs belonging to the therapeutic class of antipsychotics, zuclopenthixol may cause QT prolongation. Persistently prolonged QT intervals may increase the risk of malignant arrhythmias. Therefore, zuclopenthixol should be used with caution in susceptible individuals (with hypokalemia, hypomagnesia or genetic predisposition) and in patients with a history of cardiovascular disorders, e.g. QT prolongation, significant bradycardia (<50 beats per minute), a recent acute myocardial infarction, uncompensated heart failure, or cardiac arrhythmia.
Cases of venous thromboembolism (VTE) have been reported with antipsychotic drugs. Since patients treated with antipsychotics often present with acquired risk factors for VTE, all possible risk factors for VTE should be identified before and during treatment with Clopixol and preventive measures undertaken.
Concomitant treatment with other antipsychotics should be avoided (see section 4.5).
As described for other psychotropics zuclopenthixol may modify insulin and glucose responses calling for adjustment of the antidiabetic therapy in diabetic patients.
Increased Mortality in Elderly people with Dementia
Data from two large observational studies showed that elderly people with dementia who are treated with antipsychotics are at a small increased risk of death compared with those who are not treated. There are insufficient data to give a firm estimate of the precise magnitude of the risk and the cause of the increased risk is not known.
Clopixol is not licensed for the treatment of dementia-related behavioural disturbances.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
In common with other antipsychotics, zuclopenthixol enhances the response to alcohol, the effects of barbiturates and other CNS depressants.
Zuclopenthixol may potentiate the effects of general anaesthetics and anticoagulants and prolong the action of neuromuscular blocking agents.
The anticholinergic effects of atropine or other drugs with anticholinergic properties may be increased.
Concomitant use of drugs such as metoclopramide, piperazine or antiparkinson drugs may increase the risk of extrapyramidal effects such as tardive dyskinesia.
Combined use of antipsychotics and lithium or sibutramine has been associated with an increased risk of neurotoxicity.
Antipsychotics may enhance the cardiac depressant effects of quinidine; the absorption of corticosteroids and digoxin.
The hypotensive effect of vasodilator antihypertensive agents such as hydralazine and α blockers (e.g. doxazosin), or methyl-dopa may be enhanced.
Increases in the QT interval related to antipsychotic treatment may be exacerbated by the co administration of other drugs known to significantly increase the QT interval. Co-administration of such drugs should be avoided.
Relevant classes include:
• class Ia and III antiarrhythmics (e.g. quinidine, amiodarone, sotalol, dofetilide)
• some antipsychotics (e.g. thioridazine)
• some macrolides (e.g. erythromycin)
• some antihistamines
• some quinolone antibiotics (e.g. moxifloxacin)
The above list is not exhaustive and other individual drugs known to significantly increase QT interval (e.g. cisapride, lithium) should be avoided. Drugs known to cause electrolyte disturbances such as thiazide diuretics (hypokalemia) and drugs known to increase the plasma concentration of zuclopenthixol should also be used with caution as they may increase the risk of QT prolongation and malignant arrhythmias (see section 4.4).
Antipsychotics may antagonise the effects of adrenaline and other sympathomimetic agents, and reverse the antihypertensive effects of guanethidine and similar adrenergic-blocking agents.
Antipsychotics may also impair the effect of levodopa, adrenergic drugs and anticonvulsants.
The metabolism of tricyclic antidepressants may be inhibited and the control of diabetes may be impaired.
Since zuclopenthixol is partly metabolised by CYP2D6 concomitant use of drugs known to inhibit this enzyme may lead to to higher than expected plasma concentrations of zuclopenthixol, increasing the risk of adverse effects and cardiotoxicity.
4.6 Pregnancy And Lactation
Pregnancy
Zuclopenthixol should not be administered during pregnancy unless the expected benefit to the patient outweighs the theoretical risk to the foetus.
The newborn of mothers treated with neuroleptics in late pregnancy, or labour, may show signs of intoxication such as lethargy, tremor and hyper excitability, and have a low Apgar score.
Animal-reproduction studies have not given evidence of an increased incidence of foetal damage or other deleterious effects on the reproduction process.
Lactation
As zuclopenthixol is found in breast milk in low concentrations it is not likely to affect the infant when therapeutic doses are used. The dose ingested by the infant is less than 1% of the weight related maternal dose (in mg/kg). Breast-feeding can be continued during zuclopenthixol therapy if considered of clinical importance but observation of the infant is recommended, particularly in the first 4 weeks after giving birth.
4.7 Effects On Ability To Drive And Use Machines
Zuclopenthixol is a sedative drug.
Alertness may be impaired, especially at the start of treatment, or following the consumption of alcohol; patients should be warned of this risk and advised not to drive or operate machinery until their susceptibility is known.
Patients should not drive if they have blurred vision.
4.8 Undesirable Effects
Undesirable effects are for the majority dose dependent. The frequency and severity are most pronounced in the early phase of treatment and decline during continued treatment.
Extrapyramidal reactions may occur, especially in the early phase of treatment. In most cases these side effects can be satisfactorily controlled by reduction of dosage and/or use of antiparkinsonian drugs. The routine prophylactic use of antiparkinsonian drugs is not recommended.
Antiparkinsonian drugs do not alleviate tardive dyskinsea and may aggravate them. Reduction in dosage or, if possible, discontinuation of zuclopenthixol therapy is recommeneded. In persistent akathisia a benzodiazepine or propranolol may be useful.
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As with other drugs belonging to the therapeutic class of antipsychotics, rare cases of QT prolongation, ventricular arrhythmias - ventricular fibrillation, ventricular tachycardia, Torsade de Pointes and sudden unexplained death have been reported for zuclopenthixol (see section 4.4).
Cases of venous thromboembolism, including cases of pulmonary embolism and cases of deep vein thrombosis have been reported with antipsychotic drugs- Frequency unknown.
Abrupt discontinuation of zuclopenthixol may be accompanied by withdrawal symptoms. The most common symptoms are nausea, vomiting, anorexia, diarrhoea, rhinorrhoea, sweating, myalgias, paraesthesias, insomnia, restlessness, anxiety, and agitation. Patients may also experience vertigo, alternate feelings of warmth and coldness, and tremor. Symptoms generally begin within 1 to 4 days of withdrawal and abate within 7 to 14 days.
4.9 Overdose
Symptoms: somnolence, coma, extrapyramidal symptoms, convulsions, hypotension, shock, hyper or hypothermia. ECG changes, QT prolongation, Torsade de Pointes, cardiac arrest and ventricular arrhythmias have been reported when administered in overdose together with drugs known to affect the heart.
Treatment: treatment is symptomatic and supportive. Measures aimed at supporting the respiratory and cardiovascular systems should be instituted. Adrenaline (epinephrine) must not be used in these patients. There is no specific antidote.
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
Zuclopenthixol is a potent neuroleptic of the thioxanthene series with a piperazine side-chain. The antipsychotic effect of neuroleptics is related to their dopamine receptor blocking effect. The thioxanthenes have a high affinity for both the adenylate cyclase coupled dopamine D1 receptors and for the dopamine D2 receptors; in the phenothiazine group the affinity for D1 receptors is much lower than that for D2 receptors, whereas butyrophenones, diphenylbutylpiperidines and benzamides only have affinity for D2 receptors.
In the traditional tests for antipsychotic effect, e.g. antagonism of stereotypic behaviour induced by dopamine agonists, the chemical groups of neuroleptics mentioned reveal equal but dosage dependent activity. However, the antistereotypic effect of phenothiazines, butyrophenones, diphenylbutylpiperidines, and benzamindes is strongly counteracted by the anticholinergic drug, scopolamine, while the antisteriotypic effect of the thioxanthenes, e.g. zuclopenthixol, is not, or only very slightly, influenced by concomitant treatment with anticholinergics.
5.2 Pharmacokinetic Properties
By esterification of zuclopenthixol with acetic acid, zuclopenthixol has been converted to a more lipophilic substance, zuclopenthixol acetate. When dissolved in oil and injected intramuscularly this substance diffuses slowly into the surrounding body water, where enzymatic breakdown occurs releasing the active component zuclopenthixol.
Maximum serum concentrations of zuclopenthixol are usually reached 36 hours after an injection, after which the serum levels decline slowly. The average maximum serum level corresponding to the 100 mg dose is 41 ng/mL.
Three days after the injection the serum level is about one third of the maximum.
Zuclopenthixol is distributed in the body in a similar way to other neuroleptics; with the higher concentrations of drug and metabolites in liver, lungs, intestines and kidneys and lower concentrations in heart, spleen, brain and blood. The apparent volume of distribution is about 20 L/kg and the protein binding about 98%.
Zuclopenthixol crosses the placental barrier in small amounts. Zuclopenthixol is excreted in small amounts with the milk - the ratio milk concentration/serum concentration in women is on average 0.3.
The metabolism of zuclopenthixol proceeds via three main routes - sulphoxidation, side chain N-dealkylation and glucuronic acid conjugation.
The metabolites are devoid of psychopharmacolical activity. The excretion proceeds mainly with the faeces but also to some degree with the urine. The systemic clearance is about 0.9 L/min.
The kinetics seem to be linear, since highly significant correlation exist between the dose and the area under the serum concentration curve.
5.3 Preclinical Safety Data
Zuclopenthixol has no mutagenic potential. In a rat oncogenicity study, 30 mg/kg/day resulted in slight non statistical increases in the incidence of mammary adenocarcinomas and pancreatic islet cell adenomas and carcinomas in females of thyroid parafollicular carcinomas. This is a common finding for D2 antagonists which increase prolactin secretion when administered to rats. The physiological differences between rats and humans suggest that these changes are not predictive of an oncogenic risk in patients.
Local muscle damage is less pronounced with oily solutions of zuclopenthixol (including Clopixol Acuphase) then with aqueous solutions of zuclopenthixol and other neuroleptics.
6. Pharmaceutical Particulars
6.1 List Of Excipients
Thin vegetable oil (derived from coconuts).
6.2 Incompatibilities
Zuclopenthixol acetate should not be mixed with other injection fluids.
6.3 Shelf Life
2 years as packaged for sale.
6.4 Special Precautions For Storage
Store at or below 25°C. Protect from light.
6.5 Nature And Contents Of Container
Clear glass ampoules containing either 1 or 2 mL of zuclopenthixol acetate 5%
w/v in thin vegetable oil.
The ampoules are packed in boxes of 5.
6.6 Special Precautions For Disposal And Other Handling
Nil.
7. Marketing Authorisation Holder
Lundbeck Limited
Lundbeck House
Caldecotte Lake Business Park
Caldecotte
Milton Keynes
MK7 8LF
8. Marketing Authorisation Number(S)
PL 00458/0063
9. Date Of First Authorisation/Renewal Of The Authorisation
First authorised in UK: 16 March 1990
Renewal due: 8 May 2006
10. Date Of Revision Of The Text
28/01/2010
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