Claxid

Claxid may be available in the countries listed below.

Ingredient matches for Claxid

Clarithromycin

Clarithromycin is reported as an ingredient of Claxid in the following countries:

• Peru

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Arovan

Arovan may be available in the countries listed below.

Ingredient matches for Arovan

Valsartan

Valsartan is reported as an ingredient of Arovan in the following countries:

• Bangladesh

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Chlokinan L

Chlokinan L may be available in the countries listed below.

Ingredient matches for Chlokinan L

Chlormadinone

Chlormadinone 17α-acetate (a derivative of Chlormadinone) is reported as an ingredient of Chlokinan L in the following countries:

• Japan

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Acido Alendronico Semanal Dermogen

Acido Alendronico Semanal Dermogen may be available in the countries listed below.

Ingredient matches for Acido Alendronico Semanal Dermogen

Alendronic Acid

Alendronic Acid sodium trihydrate (a derivative of Alendronic Acid) is reported as an ingredient of Acido Alendronico Semanal Dermogen in the following countries:

• Spain

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Trazodone Teva

Trazodone Teva may be available in the countries listed below.

Ingredient matches for Trazodone Teva

Trazodone

Trazodone hydrochloride (a derivative of Trazodone) is reported as an ingredient of Trazodone Teva in the following countries:

• Belgium

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Laxin

Laxin may be available in the countries listed below.

Ingredient matches for Laxin

Bisacodyl

Bisacodyl is reported as an ingredient of Laxin in the following countries:

• Ethiopia

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Elcofar

Elcofar may be available in the countries listed below.

Ingredient matches for Elcofar

Omeprazole

Omeprazole is reported as an ingredient of Elcofar in the following countries:

• Greece

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Aciclovir akut Creme-1 A Pharma

Aciclovir akut Creme-1 A Pharma may be available in the countries listed below.

Ingredient matches for Aciclovir akut Creme-1 A Pharma

Acyclovir

Aciclovir is reported as an ingredient of Aciclovir akut Creme-1 A Pharma in the following countries:

• Germany

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Predsol

Predsol may be available in the countries listed below.

In some countries, this medicine may only be approved for veterinary use.

Ingredient matches for Predsol

Prednisolone

Prednisolone 21-(disodium phosphate) (a derivative of Prednisolone) is reported as an ingredient of Predsol in the following countries:

• Australia


• Ireland


• United Kingdom

Prednisolone 21-acetate (a derivative of Prednisolone) is reported as an ingredient of Predsol in the following countries:

• Dominican Republic


• Honduras

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Reisfit

Reisfit may be available in the countries listed below.

In some countries, this medicine may only be approved for veterinary use.

Ingredient matches for Reisfit

Cyclizine

Cyclizine hydrochloride (a derivative of Cyclizine) is reported as an ingredient of Reisfit in the following countries:

• Netherlands

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Indobufene Ranbaxy

Indobufene Ranbaxy may be available in the countries listed below.

Ingredient matches for Indobufene Ranbaxy

Indobufen

Indobufen is reported as an ingredient of Indobufene Ranbaxy in the following countries:

• Italy

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Graceptor

Graceptor may be available in the countries listed below.

Ingredient matches for Graceptor

Tacrolimus

Tacrolimus monohydrate (a derivative of Tacrolimus) is reported as an ingredient of Graceptor in the following countries:

• Japan

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Eftilora

Eftilora may be available in the countries listed below.

Ingredient matches for Eftilora

Loratadine

Loratadine is reported as an ingredient of Eftilora in the following countries:

• Vietnam

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Prepacort H

Prepacort H may be available in the countries listed below.

Ingredient matches for Prepacort H

Benzocaine

Benzocaine is reported as an ingredient of Prepacort H in the following countries:

• Italy

Cortisone

Cortisone 21-acetate (a derivative of Cortisone) is reported as an ingredient of Prepacort H in the following countries:

• Italy

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Cladribine for Injection

Ingredient matches for Cladribine for Injection

Cladribine

Cladribine is reported as an ingredient of Cladribine for Injection in the following countries:

• United States

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Tropivag

Tropivag may be available in the countries listed below.

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Estriol

Estriol is reported as an ingredient of Tropivag in the following countries:

• Peru

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Arket

Arket may be available in the countries listed below.

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Ketoprofen

Ketoprofen is reported as an ingredient of Arket in the following countries:

• China

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Trimox

In the US, Trimox (amoxicillin systemic) is a member of the drug class aminopenicillins and is used to treat Actinomycosis, Anthrax Prophylaxis, Bacterial Endocarditis Prevention, Bacterial Infection, Bladder Infection, Bronchitis, Chlamydia Infection, Cutaneous Bacillus anthracis, Dental Abscess, Helicobacter Pylori Infection, Lyme Disease - Arthritis, Lyme Disease - Carditis, Lyme Disease - Erythema Chronicum Migrans, Lyme Disease - Neurologic, Otitis Media, Pneumonia, Sinusitis, Skin Infection, Tonsillitis/Pharyngitis, Upper Respiratory Tract Infection and Urinary Tract Infection.

US matches:

• Trimox


• Trimox Suspension

Ingredient matches for Trimox

Amoxicillin

Amoxicillin trihydrate (a derivative of Amoxicillin) is reported as an ingredient of Trimox in the following countries:

• United States

International Drug Name Search

Cuplex

Cuplex may be available in the countries listed below.

Ingredient matches for Cuplex

Lactic Acid

Lactic Acid is reported as an ingredient of Cuplex in the following countries:

• United Kingdom

Salicylic Acid

Salicylic Acid is reported as an ingredient of Cuplex in the following countries:

• United Kingdom

International Drug Name Search

Ikotril

Ikotril may be available in the countries listed below.

Ingredient matches for Ikotril

Nicorandil

Nicorandil is reported as an ingredient of Ikotril in the following countries:

• Greece

International Drug Name Search

Gen-Metoprolol

Gen-Metoprolol may be available in the countries listed below.

Ingredient matches for Gen-Metoprolol

Metoprolol

Metoprolol tartrate (a derivative of Metoprolol) is reported as an ingredient of Gen-Metoprolol in the following countries:

• Canada

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Mysolane

Mysolane may be available in the countries listed below.

In some countries, this medicine may only be approved for veterinary use.

Ingredient matches for Mysolane

Primidone

Primidone is reported as an ingredient of Mysolane in the following countries:

• France

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Piremix

Piremix may be available in the countries listed below.

In some countries, this medicine may only be approved for veterinary use.

Ingredient matches for Piremix

Aspirin

Acetylsalicylic Acid is reported as an ingredient of Piremix in the following countries:

• Italy

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Loperamida Ratiopharm

Loperamida Ratiopharm may be available in the countries listed below.

Ingredient matches for Loperamida Ratiopharm

Loperamide

Loperamide is reported as an ingredient of Loperamida Ratiopharm in the following countries:

• Portugal

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Logirène

Logirène may be available in the countries listed below.

Ingredient matches for Logirène

Amiloride

Amiloride hydrochloride dihydrate (a derivative of Amiloride) is reported as an ingredient of Logirène in the following countries:

• France

Furosemide

Furosemide is reported as an ingredient of Logirène in the following countries:

• France

International Drug Name Search

Emericid

Emericid may be available in the countries listed below.

In some countries, this medicine may only be approved for veterinary use.

Ingredient matches for Emericid

Sulfadimethoxine

Sulfadimethoxine is reported as an ingredient of Emericid in the following countries:

• France

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Lawarin

Lawarin may be available in the countries listed below.

Ingredient matches for Lawarin

Warfarin

Warfarin clathrate sodium salt (a derivative of Warfarin) is reported as an ingredient of Lawarin in the following countries:

• Czech Republic


• Slovakia

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Meropex

Meropex may be available in the countries listed below.

Ingredient matches for Meropex

Meropenem

Meropenem is reported as an ingredient of Meropex in the following countries:

• Indonesia

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Pyridoxin Leciva

Pyridoxin Leciva may be available in the countries listed below.

Ingredient matches for Pyridoxin Leciva

Pyridoxine

Pyridoxine hydrochloride (a derivative of Pyridoxine) is reported as an ingredient of Pyridoxin Leciva in the following countries:

• Czech Republic


• Slovakia

International Drug Name Search

Hidroclorotiazida Iqfarma

Hidroclorotiazida Iqfarma may be available in the countries listed below.

Ingredient matches for Hidroclorotiazida Iqfarma

Hydrochlorothiazide

Hydrochlorothiazide is reported as an ingredient of Hidroclorotiazida Iqfarma in the following countries:

• Peru

International Drug Name Search

Ramprazole

Ramprazole may be available in the countries listed below.

Ingredient matches for Ramprazole

Rabeprazole

Rabeprazole is reported as an ingredient of Ramprazole in the following countries:

• Vietnam

International Drug Name Search

Trimetox

Trimetox may be available in the countries listed below.

In some countries, this medicine may only be approved for veterinary use.

Ingredient matches for Trimetox

Sulfadoxine

Sulfadoxine is reported as an ingredient of Trimetox in the following countries:

• Germany

Sulfamerazine

Sulfamerazine is reported as an ingredient of Trimetox in the following countries:

• Germany

Trimethoprim

Trimethoprim is reported as an ingredient of Trimetox in the following countries:

• Germany

International Drug Name Search

Trogine

Trogine may be available in the countries listed below.

Ingredient matches for Trogine

Lamotrigine

Lamotrigine is reported as an ingredient of Trogine in the following countries:

• Poland

International Drug Name Search

Isopelet

Isopelet may be available in the countries listed below.

Ingredient matches for Isopelet

Isosorbide Dinitrate

Isosorbide Dinitrate is reported as an ingredient of Isopelet in the following countries:

• Czech Republic


• Slovakia

International Drug Name Search

F. S.H. P

In some countries, this medicine may only be approved for veterinary use.

Ingredient matches for F.S.H. P

Follicle Stimulating Hormone

Follitropin Alfa is reported as an ingredient of F.S.H. P in the following countries:

• United States

International Drug Name Search

Lotencin

Lotencin may be available in the countries listed below.

Ingredient matches for Lotencin

Terazosin

Terazosin hydrochloride (a derivative of Terazosin) is reported as an ingredient of Lotencin in the following countries:

• Philippines

International Drug Name Search

Gevramycin

Gevramycin may be available in the countries listed below.

Ingredient matches for Gevramycin

Gentamicin

Gentamicin sulfate (a derivative of Gentamicin) is reported as an ingredient of Gevramycin in the following countries:

• Spain

International Drug Name Search

Metformin Aristo

Metformin Aristo may be available in the countries listed below.

Ingredient matches for Metformin Aristo

Metformin

Metformin hydrochloride (a derivative of Metformin) is reported as an ingredient of Metformin Aristo in the following countries:

• Germany

International Drug Name Search

Bimaclox

Bimaclox may be available in the countries listed below.

In some countries, this medicine may only be approved for veterinary use.

Ingredient matches for Bimaclox

Cloxacillin

Cloxacillin benzathine (a derivative of Cloxacillin) is reported as an ingredient of Bimaclox in the following countries:

• United Kingdom

International Drug Name Search

Flixoderm

Flixoderm may be available in the countries listed below.

Ingredient matches for Flixoderm

Fluticasone

Fluticasone propionate (a derivative of Fluticasone) is reported as an ingredient of Flixoderm in the following countries:

• Italy

International Drug Name Search

Cerulisina

Cerulisina may be available in the countries listed below.

Ingredient matches for Cerulisina

Xylene

Xylene is reported as an ingredient of Cerulisina in the following countries:

• Italy

International Drug Name Search

Ketek 400mg Tablets (sanofi-aventis)

1. Name Of The Medicinal Product

Ketek 400 mg film-coated tablets

2. Qualitative And Quantitative Composition

Each film-coated tablet contains 400 mg of telithromycin.

For a full list of excipients, see section 6.1.

3. Pharmaceutical Form

Film-coated tablet.

Light orange, oblong, biconvex tablet, imprinted with 'H3647' on one side and '400' on the other.

4. Clinical Particulars

4.1 Therapeutic Indications

When prescribing Ketek, consideration should be given to official guidance on the appropriate use of antibacterial agents and the local prevalence of resistance (see also sections 4.4 and 5.1).

Ketek is indicated for the treatment of the following infections:

In patients of 18 years and older:

• Community-acquired pneumonia, mild or moderate (see section 4.4).

• When treating infections caused by known or suspected beta-lactam and/or macrolide resistant strains (according to history of patients or national and/or regional resistance data) covered by the antibacterial spectrum of telithromycin (see sections 4.4 and 5.1):

       - Acute exacerbation of chronic bronchitis,

       - Acute sinusitis

In patients of 12 years and older:

• Tonsillitis/pharyngitis caused by Streptococcus pyogenes, as an alternative when beta lactam antibiotics are not appropriate in countries/regions with a significant prevalence of macrolide resistant S. pyogenes, when mediated by ermTR or mefA (see sections 4.4 and 5.1).

4.2 Posology And Method Of Administration

Posology

The recommended dose is 800 mg once a day i.e. two 400 mg tablets once a day.

In patients of 18 years and older, according to the indication, the treatment regimen will be:

- Community-acquired pneumonia: 800 mg once a day for 7 to 10 days,

- Acute exacerbation of chronic bronchitis: 800 mg once a day for 5 days,

- Acute sinusitis: 800 mg once a day for 5 days,

- Tonsillitis/pharyngitis caused by Streptococcus pyogenes: 800 mg once a day for 5 days.

In patients of 12 to 18 years old, the treatment regimen will be:

- Tonsillitis/pharyngitis caused by Streptococcus pyogenes: 800 mg once a day for 5 days.

Elderly population

No dosage adjustment is required in elderly patients based on age alone.

Paediatric population:

The safety and efficacy of Ketek in children below 12 years of age have not been established (see section 5.2). Ketek is not recommended in this population.

Renal impairment

No dosage adjustment is necessary in patients with mild or moderate renal impairment. Ketek is not recommended as first choice in patients with severe renal impairment (creatinine clearance <30 ml/min) or patients with both severe renal impairment and co-existing hepatic impairment, as an optimal dosage format (600 mg) is not available. If telithromycin treatment is deemed necessary, these patients may be treated with alternating daily doses of 800 mg and 400 mg, starting with the 800 mg dose.

In haemodialysed patients, the posology should be adjusted so that Ketek 800 mg is given after the dialysis session (see also section 5.2).

Hepatic impairment

No dosage adjustment is necessary in patients with mild, moderate, or severe hepatic impairment, however the experience in patients with impaired hepatic function is limited. Hence, telithromycin should be used with caution (see also sections 4.4 and 5.2).

Method of administration

The tablets should be swallowed whole with a sufficient amount of water. The tablets may be taken with or without food.

Consideration may be given to taking Ketek at bedtime, to reduce the potential impact of visual disturbances and loss of consciousness (see section 4.4).

4.3 Contraindications

Hypersensitivity to the active substance, to any of the macrolide antibacterial agents, or to any of the excipients.

Myasthenia gravis (see section 4.4).

Previous history of hepatitis and/or jaundice associated with the use of telithromycin.

Concomitant administration with any of the following substances: cisapride, ergot alkaloid derivatives (such as ergotamine and dihydroergotamine), pimozide, astemizole and terfenadine (see section 4.5).

Concomitant administration with simvastatin, atorvastatin, and lovastatin. Treatment with these agents should be interrupted during Ketek treatment (see section 4.5).

History of congenital or a family history of long QT syndrome (if not excluded by ECG) and in patients with known acquired QT interval prolongation.

In patients with severely impaired renal and/or hepatic function, concomitant administration of Ketek and strong CYP3A4 inhibitors, such as protease inhibitors or ketoconazole, is contraindicated.

4.4 Special Warnings And Precautions For Use

QT interval prolongation

Due to a potential to increase QT interval, Ketek should be used with care in patients with coronary heart disease, a history of ventricular arrhythmias, uncorrected hypokalaemia and or hypomagnesaemia, bradycardia (<50 bpm), or during concomitant administration of Ketek with QT interval prolonging agents or potent CYP 3A4 inhibitors such as protease inhibitors and ketoconazole.

Clostridium difficile-associated disease

Diarrhoea, particularly if severe, persistent and /or bloody, during or after treatment with Ketek may be caused by pseudomembranous colitis (see section 4.8). If pseudomembranous colitis is suspected, the treatment must be stopped immediately and patients should be treated with supportive measures and/or specific therapy.

Myasthenia gravis

Exacerbations of myasthenia gravis have been reported in patients treated with telithromycin and sometimes occurred within a few hours of the first dose. Reports have included death and life threatening acute respiratory failure with rapid onset (see section 4.8).

Hepatobiliary disordes

Alterations in hepatic enzymes have been commonly observed in clinical studies with telithromycin. Post-marketing cases of severe hepatitis and liver failure, including fatal cases (which have generally been associated with serious underlying diseases or concomitant medicinal products), have been reported (see section 4.8). These hepatic reactions were observed during or immediately after treatment, and in most cases were reversible after discontinuation of telithromycin.

Patients should be advised to stop treatment and contact their doctor if signs and symptoms of hepatic disease develop such as anorexia, jaundice, dark urine, pruritus or tender abdomen.

Due to limited experience, Ketek should be used with caution in patients with liver impairment (see section 5.2).

Visual disturbances

Ketek may cause visual disturbances particularly in slowing the ability to accommodate and the ability to release accommodation. Visual disturbances included blurred vision, difficulty focusing, and diplopia. Most events were mild to moderate; however, severe cases have been reported (see sections 4.7 and 4.8).

Loss of consciousness

There have been post-marketing adverse reaction reports of transient loss of consciousness including some cases associated with vagal syndrome (see sections 4.7 and 4.8).

Consideration may be given to taking Ketek at bedtime, to reduce the potential impact of visual disturbances and loss of consciousness.

CYP3A4 inducers

Ketek should not be used during and 2 weeks after treatment with CYP3A4 inducers (such as rifampicin, phenytoin, carbamazepine, phenobarbital, St John's wort). Concomitant treatment with these medicinal products is likely to result in subtherapeutic levels of telithromycin and therefore encompass a risk of treatment failure (see section 4.5).

CYP3A4 substrates

Ketek is an inhibitor of CYP3A4 and should only be used under specific circumstances during treatment with other medicinal products that are metabolised by CYP3A4. Patients with concomitant treatment of pravastatin, rosuvastatin or fluvastatin should be carefully monitored for signs and symptoms of myopathy and rhabdomyolysis (see sections 4.3 and 4.5).

Resistance

In areas with a high incidence of erythromycin A resistance, it is especially important to take into consideration the evolution of the pattern of susceptibility to telithromycin and other antibiotics.

In community acquired pneumonia, efficacy has been demonstrated in a limited number of patients with risk factors such as pneumococcal bacteraemia or age higher than 65 years.

Experience of treatment of infections caused by penicillin/or erythromycin resistant S. pneumoniae is limited, but so far, clinical efficacy and eradication rates have been similar compared with the treatment of susceptible S. pneumoniae. Caution should be taken when S. aureus is the suspected pathogen and there is a likelihood of erythromycin resistance based on local epidemiology.

L. pneumophila is highly susceptible to telithromycin in vitro, however, the clinical experience of the treatment of pneumonia caused by legionella is limited.

As for macrolides, H. influenzae is classified as intermediately susceptible. This should be taken into account when treating infections caused by H. influenzae.

4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction

Interaction studies have only been performed in adults.

• Effect of Ketek on other medicinal products

Telithromycin is an inhibitor of CYP3A4 and a weak inhibitor of CYP2D6. In vivo studies with simvastatin, midazolam and cisapride have demonstrated a potent inhibition of intestinal CYP3A4 and a moderate inhibition of hepatic CYP3A4. The degree of inhibition with different CYP3A4 substrates is difficult to predict. Hence, Ketek should not be used during treatment with medicinal products that are CYP3A4 substrates, unless plasma concentrations of the CYP3A4 substrate, efficacy or adverse reactions can be closely monitored. Alternatively, interruption in the treatment with the CYP3A4 substrate should be made during treatment with Ketek.

Cyclosporin, tacrolimus, sirolimus

Due to its CYP3A4 inhibitory potential, telithromycin can increase blood concentrations of these CYP34A4 substrates. Thus, when initiating telithromycin in patients already receiving any of theses immunosuppressive agents, cyclosporin, tacrolimus or sirolimus levels must be carefully monitored and their doses decreased as necessary. When telithromycin is discontinued, cyclosporin, tacrolimus or sirolimus levels must be again carefully monitored and their dose increased as necessary.

Metoprolol

When metoprolol (a CYP2D6 substrate) was coadministered with Ketek, metropolol C_max and AUC were increased by approximately 38%, however, there was no effect on the elimination half-life of metoprolol. The increase exposure to metoprolol may be of clinical importance in patients with heart failure treated with metoprolol. In these patients, co-administration of Ketek and metoprolol, a CYP2D6 substrate, should be considered with caution.

Medicinal products with a potential to prolong QT interval

Ketek is expected to increase the plasma levels of cisapride, pimozide, astemizole and terfenadine. This could result in QT interval prolongation and cardiac arrhythmias including ventricular tachycardia, ventricular fibrillation and torsades de pointes. Concomitant administration of Ketek and any of these medicinal products is contraindicated (see section 4.3).

Caution is warranted when Ketek is administered to patients taking other medicinal products with the potential to prolong QT interval (see section 4.4).

Ergot alkaloid derivatives (such as ergotamine and dihydroergotamine)

By extrapolation from erythromycin A and josamycin, concomitant medication of Ketek and alkaloid derivatives could lead to severe vasoconstriction (“ergotism”) with possibly necrosis of the extremities. The combination is contraindicated (see section 4.3).

Statins

When simvastatin was coadministered with Ketek, there was a 5.3 fold increase in simvastatin C_max, an 8.9 fold increase in simvastatin AUC, a 15-fold increase in simvastatin acid C_max and an 11-fold increase in simvastatin acid AUC. Ketek may produce a similar interaction with lovastatin and atorvastatin which are also mainly metabolised by CYP3A4. Ketek should therefore not be used concomitantly with simvastatin, atorvastatin, or lovastatin (see section 4.3). Treatment with these agents should be interrupted during Ketek treatment. The exposure of pravastatin, rosuvastatin and to a lesser extent fluvastatin, may be increased due to possible involvement of transporters proteins, but this increase is expected to be lesser than interactions involving CYP3A4 inhibition. However, patients should be carefully monitored for signs and symptoms of myopathy and rhabdomyolysis when co-treated with pravastatin, rosuvastatin and fluvastatin.

Benzodiazepines

When midazolam was coadministered with Ketek, midazolam AUC was increased 2.2-fold after intravenous administration of midazolam and 6.1-fold after oral administration. The midazolam half-life was increased about 2.5-fold. Oral administration of midazolam concomitantly with Ketek should be avoided. Intravenous dosage of midazolam should be adjusted as necessary and monitoring of the patient should be undertaken. The same precautions should also apply to the other benzodiazepines which are metabolised by CYP3A4, (especially triazolam but also to a lesser extent alprazolam). For those benzodiazepines which are not metabolised by CYP3A4 (temazepam, nitrazepam, lorazepam) an interaction with Ketek is unlikely.

Digoxin

Ketek has been shown to increase the plasma concentrations of digoxin. The plasma trough levels, C_max, AUC and renal clearance were increased by 20%, 73%, 37% and 27% respectively, in healthy volunteers. There were no significant changes in ECG parameters and no signs of digoxin toxicity were observed. Nevertheless, monitoring of serum digoxin level should be considered during concomitant administration of digoxin and Ketek.

Theophylline

There is no clinically relevant pharmacokinetic interaction of Ketek and theophylline administered as extended release formulation. However, the co-administration of both medicinal products should be separated by one hour in order to avoid possible digestive side effects such as nausea and vomiting.

Oral anticoagulants

Increased anticoagulant activity has been reported in patients simultaneously treated with anticoagulants and antibiotics, including telithromycin. The mechanisms are incompletely known. Although Ketek has no clinically relevant pharmacokinetic or pharmacodynamic interaction with warfarin after single dose administration, more frequent monitoring of prothrombin time/INR (International Normalised Ratio) values should be considered during concomitant treatment.

Oral contraceptives

There is no pharmacodynamic or clinically relevant pharmacokinetic interaction with low-dose triphasic oral contraceptives in healthy subjects.

• Effect of other medicinal products on Ketek

During concomitant administration of rifampicin and telithromycin in repeated doses, C_max and AUC of telithromycin were on average decreased by 79% and 86% respectively. Therefore, concomitant administration of CYP3A4 inducers (such as rifampicin, phenytoin, carbamazepine, phenobarbital, St John's wort) is likely to result in subtherapeutic levels of telithromycin and loss of effect. The induction gradually decreases during 2 weeks after cessation of treatment with CYP3A4 inducers. Ketek should not be used during and 2 weeks after treatment with CYP3A4 inducers.

Interaction studies with itraconazole and ketoconazole, two CYP3A4 inhibitors, showed that maximum plasma concentrations of telithromycin were increased respectively by 1.22 and 1.51 fold and AUC by respectively 1.54 fold and 2.0 fold. These changes in the pharmacokinetics of telithromycin do not necessitate dosage adjustment as telithromycin exposure remains within a well tolerated range. The effect of ritonavir on telithromycin has not been studied and could lead to larger increase in telithromycin exposure. The combination should be used with caution.

Strong CYP3A4 inhibitors must not be co-administered with Ketek in patients with severe renal/or hepatic dysfunction (see section 4.3).

Ranitidine (taken 1 hour before Ketek) and antacid containing aluminium and magnesium hydroxide has no clinically relevant influence on telithromycin pharmacokinetics.

4.6 Pregnancy And Lactation

Pregnancy

There are no adequate data from the use of Ketek in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3). The potential risk for humans is unknown. Ketek should not be used during pregnancy unless clearly necessary.

Breastfeeding

Telithromycin is excreted in the milk of lactating animals, at concentrations about 5 times those of maternal plasma. Corresponding data for humans is not available. Ketek should not be used by breast-feeding women.

Fertility

In studies with rats a reduction in fertility indices was observed at parentally toxic doses.(see section 5.3).

4.7 Effects On Ability To Drive And Use Machines

Ketek may cause adverse reactions such as visual disturbances, confusion or hallucination which may reduce the capacity for the completion of certain tasks. In addition, rare cases of transient loss of consciousness, which may be preceded by vagal symptoms, have been reported (see section 4.8). Because of potential visual difficulties, loss of consciousness, confusion or hallucination, patients should attempt to minimize activities such as driving a motor vehicle, operating heavy machinery or engaging in other hazardous activities during treatment with Ketek. If patients experience visual disorders, loss of consciousness, confusion or hallucination while taking Ketek, patients should not drive a motor vehicle, operate heavy machinery or engage in other hazardous activities (see sections 4.4 and 4.8).

Patients should be informed that these adverse reactions may occur as early as after the first dose of medicinal product. Patients should be cautioned about the potential effects of these events on the ability to drive or operate machinery.

4.8 Undesirable Effects

In 2,461 patients treated by Ketek in phase III clinical trials, and during post-marketing experience, the following undesirable effects possibly or probably related to telithromycin have been reported. This is shown in the table below. Diarrhoea, nausea and dizziness were the most commonly reported adverse reactions in phase III clinical trials.

Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.

System organ class	Very common (	Common (	Uncommon (	Rare (	Very rare (< 1/10,000)	Not known (cannot be estimated from the available data)*
Blood and the lymphatic system disorders			Eosinophilia
Immune system disorders						Angioneurotic oedema, anaphylactic reactions including anaphylactic shock, hyper-sensitivity
Psychiatric disorders						Confusion, hallucination
Nervous system disorders		Dizziness, headache, disturbance of taste	Vertigo somnolence, nervousness, insomnia,	Transient loss of consciousness, paraesthesia	Parosmia	Cases of rapid onset of exacerbation of myasthenia gravis have been reported (see sections 4.3 and 4.4). Ageusia, anosmia,
Eye disorders			Blurred vision	Diplopia
Cardiac disorders			Flush Palpitations	Atrial arrhythmia, hypotension, bradycardia		QT/QTc interval prolongation
Gastrointestinal disorders	Diarrhoea	Nausea, vomiting, gastrointestinal pain, flatulence	Oral Candida infection, stomatitis anorexia, constipation		Pseudomembranous colitis (see section 4.4)	Pancreatitis
Hepatobiliary disorders		Increase in liver enzymes (AST, ALT, alkaline phosphatase)	Hepatitis	Cholestatic jaundice		Severe hepatitis and liver failure (see section 4.4)
Skin and subcutaneous tissue disorders			Rash, urticaria, pruritus	Eczema	Erythema multiforme
Musculoskeletal and connective tissue disorders					Muscle cramps	Arthralgia, myalgia
Reproductive system and breast disorders		Vaginal Candida infection

*post-marketing experience

Description of selected adverse reactions

Visual disturbances (<1%) associated with the use of Ketek, including blurred vision, difficulty focusing and diplopia, were mostly mild to moderate. They typically occurred within a few hours after the first or second dose, recurred upon subsequent dosing, lasted several hours and were fully reversible either during therapy or following the end of treatment. These events have not been associated with signs of ocular abnormality (see sections 4.4 and 4.7).

In clinical trials the effect on QTc was small (mean of approximately 1 msec). In comparative trials, similar effects to those observed with clarithromycin were seen with an on-therapy ΔQTc >30 msec in 7.6% and 7.0% of cases, respectively. No patient in either group developed a ΔQTc >60 msec. There were no reports of TdP or other serious ventricular arrhythmias or related syncope in the clinical program and no subgroups at risk were identified.

4.9 Overdose

In the event of acute overdose the stomach should be emptied. The patients should be carefully observed and given symptomatic and supportive treatment. Adequate hydration should be maintained. Blood electrolytes (especially potassium) must be controlled. Due to the potential for the prolongation of the QT interval and increased risk of arrhythmia, ECG monitoring must take place.

5. Pharmacological Properties

5.1 Pharmacodynamic Properties

Pharmacotherapeutic group: antibacterials for systemic use, macrolides, lincosamides and streptogramins, ATC Code: J01FA15.

Telithromycin is a semisynthetic derivative of erythromycin A belonging to the ketolides, a class of antibacterial agents related to macrolides.

Mode of action

Telithromycin inhibits protein synthesis by interacting with domains II and V of the 23S ribosomal RNA of the 50S ribosome subunit. Furthermore, telithromycin is able to block the formation of the 50S and 30S ribosomal subunits.

The affinity of telithromycin for the 50S ribosomal subunits of organisms susceptible to erythromycin A is 10-fold higher than that of erythromycin A.

Pharmacokinetic/Pharmacodynamic (PK/PD) relationship:

The AUC/MIC ratio has been shown to be the PK/PD parameter that correlates best with the efficacy of telithromycin.

Mechanisms of resistance

Telithromycin does not induce expression of macrolide-lincosamide-streptogramin B (MLS_B)-mediated resistance in vitro in Staphylococcus aureus, Streptococcus pneumoniae, or Streptococcus pyogenes.

In some organisms that are resistant to erythromycin A due to inducible expression of the MLS_B resistance determinant, the affinity of telithromycin for the 50S ribosomal subunit is more than 20-fold that of erythromycin A.

Telithromycin is not active against organisms that constitutively express the MLS_B resistance determinant (cMLS_B). The majority of methicillin-resistant S. aureus (MRSA) express cMLS_B.

In in vitro studies the activity of telithromycin was reduced against organisms that express the erythromycin erm(B) or mef(A) related resistance mechanisms.

Exposure to telithromycin in vitro did select for pneumococcal mutants with increased MICs of telithromycin, generally resulting in MIC values of

Streptococcus pneumoniae does not demonstrate cross-resistance between erythromycin A and telithromycin.

Streptococcus pyogenes that show high-level resistance to erythromycin A are cross-resistant to telithromycin.

Breakpoints

The recommended European Committee for Antimicrobial Susceptibility Testing (EUCAST) MIC clinical breakpoints are presented below:

Pathogen	Susceptible	Resistant
Streptococcus A, B, C, G		>0.5 mg/l
Streptococcus pneumoniae		>0.5 mg/l
Haemophilus influenzae1		>8 mg/l
Moraxella catarrhalis		>0.5 mg/l

¹The correlation between macrolide MICs and clinical outcome is weak for H.influenzae. Therefore the MIC breakpoint for telithromycin was set to categorise wild-type H.influenzae as having intermediate susceptibility.

Antibacterial spectrum

The prevalence of resistance may vary geographically and with time for selected species and local information on resistance is desirable, particularly when treating severe infections. As necessary, expert advice should be sought when the local prevalence of resistance is such that the utility of the agent in at least some types of infections is questionable.

Commonly susceptible species Aerobic Gram-positive bacteria Staphylococcus aureus methicillin susceptible (MSSA)* Streptococcus pneumoniae * Streptococcus species Viridans group streptococci Aerobic Gram- negative bacteria Haemophilus influenzae$* Haemophilus parainfluenzae$ Legionella pneumophila Moraxella catarrhalis* Other Chlamydophila pneumoniae* Chlamydia psittaci Mycoplasma pneumoniae*

Species for which acquired resistance may be a problem Aerobic Gram-positive bacteria Staphylococcus aureus methicillin resistant (MRSA)+ Streptococcus pyogenes*

Inherantly resistant organisms Aerobic Gram- negative bacteria Acinetobacter Enterobacteriaceae Pseudomonas

* Clinical efficacy has been demonstrated for susceptible isolates in the approved clinical indications.

$ natural intermediate susceptibility

+ Telithromycin is not active against organisms that constitutively express the MLS_B resistance determinant (cMLS_B). More than 80%of MRSA express cMLS_B.

5.2 Pharmacokinetic Properties

Absorption

Following oral administration, telithromycin is fairly rapidly absorbed. A mean maximum plasma concentration of about 2 mg/l is reached within 1-3 hour after dose with once-daily dosing of telithromycin 800 mg. The absolute bioavailability is about 57% after a single dose of 800 mg. The rate and extent of absorption is unaffected by food intake, and thus Ketek tablets can be given without regard to food.

Mean steady-state trough plasma concentrations of between 0.04 and 0.07 mg/l are reached within 3 to 4 days with once-daily dosing of telithromycin 800 mg. At steady-state AUC is approximately 1.5 fold increased compared to the single dose.

Mean peak and trough plasma concentrations at steady state in patients were 2.9±1.6 mg/l (range 0.02-7.6 mg/l) and 0.2±0.2 mg/l (range 0.010 to 1.29 mg/l), during a therapeutic 800 mg once-daily dose regimen.

Distribution

The in vitro protein binding is approximately 60% to 70%. Telithromycin is widely distributed throughout the body. The volume of distribution is 2.9±1.0 l/kg. Rapid distribution of telithromycin into tissues results in significantly higher telithromycin concentrations in most target tissues than in plasma. The maximum total tissue concentration in epithelial lining fluid, alveolar macrophages, bronchial mucosa, tonsils and sinus tissue were 14.9±11.4 mg/l, 318.1±231 mg/l, 3.88±1.87 mg/kg, 3.95±0.53 mg/kg and 6.96±1.58 mg/kg, respectively. The total tissue concentration 24 h after dose in epithelial lining fluid, alveolar macrophages, bronchial mucosa, tonsils and sinus tissue were 0.84±0.65 mg/l, 162±96 mg/l, 0.78±0.39 mg/kg, 0.72±0.29 mg/kg and 1.58±1.68 mg/kg, respectively. The mean maximum white blood cell concentration of telithromycin was 83±25 mg/l.

Biotransformation

Telithromycin is metabolised primarily by the liver. After oral administration, two-thirds of the dose is eliminated as metabolites and one-third unchanged. The main circulating compound in plasma is telithromycin. Its principal circulating metabolite represents approximately 13% of telithromycin AUC, and has little antimicrobial activity compared with the parent medicinal product. Other metabolites were detected in plasma, urine and faeces and represent less or equal than 3% of plasma AUC.

Telithromycin is metabolised both by CYP450 isoenzymes and non-CYP enzymes. The major CYP450 enzyme involved in the metabolism of telithromycin is CYP3A4. Telithromycin is an inhibitor of CYP3A4 and CYP2D6, but has no or limited effect on CYP1A, 2A6, 2B6, 2C8, 2C9, 2C19 and 2E1.

Elimination

After oral administration of radiolabelled telithromycin, 76% of the radioactivity was recovered from faeces, and 17% from the urine. Approximately one-third of telithromycin was eliminated unchanged; 20% in faeces and 12% in urine. Telithromycin displays moderate non-linear pharmacokinetics. The non-renal clearance is decreased as the dose is increased. The total clearance (mean ±SD) is approximately 58±5 l/h after an intravenous administration with renal clearance accounting for about 22% of this. Telithromycin displays a tri-exponential decay from plasma, with a rapid distribution half-life of 0.17 h. The main elimination half-life of telithromycin is 2-3 h and the terminal, less important, half-life is about 10 h at the dose 800 mg once daily.

Special populations

-Renal impairment

In a multiple-dose study, 36 subjects with varying degrees of renal impairment, a 1.4-fold increase in C_max,ss, and a 2-fold increase in AUC (0-24)_ss at 800 mg multiple doses in the severe renally impaired group (CLCR < 30 ml/min) compared to healthy volunteers were observed and a reduced dosage of Ketek is recommended (see section 4.2.). Based on observed data, a 600 mg daily dose is approximately equivalent with the target exposure observed in healthy subjects. Based on simulation data, an alternating daily dosing regimen of 800 mg and 400 mg in patients with severe renal impairment can approximate the AUC (0-48h) in healthy subjects receiving 800 mg once daily.

The effect of dialysis on the elimination of telithromycin has not been assessed.

-Hepatic impairment

In a single-dose study (800 mg) in 12 patients and a multiple-dose study (800 mg) in 13 patients with mild to severe hepatic insufficiency (Child Pugh Class A, B and C), the C_max, AUC and t_1/2 of telithromycin were similar compared to those obtained in age- and sex-matched healthy subjects. In both studies, higher renal elimination was observed in the hepatically impaired patients. Due to limited experience in patients with decreased metabolic capacity of the liver, Ketek should be used with caution in patients with hepatic impairment (see also section 4.4).

-Elderly subjects

In subjects over 65 (median 75 years), the maximum plasma concentration and AUC of telithromycin were increased approximately 2 fold compared with those achieved in young healthy adults. These changes in pharmacokinetics do not necessitate dosage adjustment.

-Paediatric population

Limited data, obtained in paediatric patients 13 to 17 years of age, showed that telithromycin concentrations in this age group were similar to the concentrations in patients 18 to 40 years of age.

-Gender

The pharmacokinetics of telithromycin is similar between males and females.

5.3 Preclinical Safety Data

Repeated dose toxicity studies of 1, 3 and 6 month duration with telithromycin conducted in rat, dog and monkey showed that the liver was the principal target for toxicity with elevations of liver enzymes, and histological evidence of damage. These effects showed a tendency to regress after cessation of treatment. Plasma exposures based on free fraction of active substance, at the no observed adverse effect levels ranged from 1.6 to 13 times the expected clinical exposure.

Phospholipidosis (intracellular phospholipid accumulation) affecting a number of organs and tissues (e.g., liver, kidney, lung, thymus, spleen, gall bladder, mesenteric lymph nodes, GI-tract) has been observed in rats and dogs administered telithromycin at repeated doses of 150 mg/kg/day or more for 1 month and 20 mg/kg/day or more for 3-6 months. This administration corresponds to free active substance systemic exposure levels of at least 9 times the expected levels in human after 1 month and less than the expected level in humans after 6 months, respectively. There was evidence of reversibility upon cessation of treatment. The significance of these findings for humans is unknown.

In similarity to some macrolides, telithromycin caused a prolongation of QTc interval in dogs and on action potential duration in rabbit Purkinje fibers in vitro. Effects were evident at plasma levels of free drug 8 to 13 times the expected clinical level. Hypokalaemia and quinidine had additive/supra-additive effects in vitro while potentiation was evident with sotalol. Telithromycin, but not its major human metabolites, had inhibitory activity on HERG and Kv1.5 channels.

Reproduction toxicity studies showed reduced gamete maturation in rat and adverse effects on fertilization. Slight reductions in fertility indices were seen in rats at parentally toxic doses higher than 150 mg/kg. At high doses embryotoxicity was apparent and an increase in incomplete ossification and in skeletal anomalies was seen. Studies in rats and rabbits were inconclusive with respect to potential for teratogenicity; there was equivocal evidence of adverse effects on foetal development at high doses.

Telithromycin, and its principal human metabolites, were negative in tests on genotoxic potential in vitro and in vivo. No carcinogenicity studies have been conducted with telithromycin.

6. Pharmaceutical Particulars

6.1 List Of Excipients

Tablet core:

Microcrystalline cellulose

Povidone K25

Croscarmellose sodium

Magnesium stearate

Tablet coating:

Talc

Macrogol 8000

Hypromellose 6 cp

Titanium dioxide E171

Yellow iron oxide E172

Red iron oxide E172

6.2 Incompatibilities

Not applicable.

6.3 Shelf Life

3 years.

6.4 Special Precautions For Storage

This medicinal product does not require any special storage condition.

6.5 Nature And Contents Of Container

Two tablets are contained in each blister cavity.

Available as packs of 10 tablets.

Opaque PVC/Aluminium blisters

6.6 Special Precautions For Disposal And Other Handling

No special requirements.

7. Marketing Authorisation Holder

Aventis Pharma S.A.

20, Avenue Raymond Aron

F-92160 ANTONY

France

8. Marketing Authorisation Number(S)

EU/1/01/191/001

9. Date Of First Authorisation/Renewal Of The Authorisation

Date of first authorisation: 9 July 2001

Date of first renewal: 9 July 2006

10. Date Of Revision Of The Text

12 May 2011

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