Grunenthal Ltd

Zydol 100 mg / 2 ml Solution for Injection

Each ampoule Zydol 100 mg / 2 ml Solution for injection contains 100 mg tramadol hydrochloride in 2 ml solution, i.e. 50 mg tramadol hydrochloride per ml.

Excipient: 1 ml of solution for injection contains less than 1 mmol sodium.

For a full list of excipients, see section 6.1.

Solution for injection

Clear colourless, aqueous solution.

Treatment of moderate to severe pain.

Treatment periods should be short and intermittent as dependence can occur with tramadol. The benefits of continued use should be reviewed in order to ensure that they outweigh the risks of dependence (see Section 4.4 and 4.8).

The dose should be adjusted to the intensity of the pain and the sensitivity of the individual patient.

Unless otherwise prescribed, Zydol should be administered as follows:

Adults and adolescents above the age of 12 years:

Parenteral administration

Zydol solution for injection may be administered subcutaneously, intramuscularly, or by slow (given over 2-3 minutes) intravenous injection. It may also be diluted in solution for administration by infusion or patient-controlled analgesia (PCA).

The usual dosage is an initial bolus of 100 mg with subsequent doses of 50 mg to 100 mg at 4-6 hourly intervals.

The lowest analgesically effective dose should generally be selected. Daily doses of 400 mg active substance should not be exceeded, except in special clinical circumstances.

In the PCA setting it is recommended that an initial 100 mg bolus of Zydol is administered. Subsequent increments of 20 mg with a minimum interval (lock-out period) of 5 minutes between doses, up to a maximum daily dose of 400 mg has been found to provide adequate analgesia via this route.

Zydol should under no circumstances be administered for longer than absolutely necessary. If long-term pain treatment with Zydol is necessary in view of the nature and severity of the illness, then careful and regular monitoring should be carried out (if necessary with breaks in treatment) to establish whether and to what extent further treatment is necessary.

Geriatrics patients

A dose adjustment is not usually necessary in elderly patients (up to 75 years) without clinically manifest hepatic or renal insufficiency. In elderly patients (over 75 years) elimination may be prolonged. Therefore, if necessary, the dosage interval is to be extended according to the patient's requirements.

Renal Insufficiency/Dialysis and Hepatic Insufficiency

In patients with impaired hepatic or renal function the elimination of tramadol may be prolonged. In these patients prolongation of dosage intervals should be carefully considered according to the patient's requirements. It is recommended that the usual initial dosage be used and when repeated dosing is required the interval between doses is extended by a factor of 2. Subsequent dosing should be adjusted dependent on the frequency of recurrence of pain.

Tramadol is removed very slowly by haemodialysis or haemofiltration, therefore post-dialysis administration to maintain analgesia is not usually necessary.

Children above the age of 1 year

The recommended single dose of tramadol hydrochloride is 1 mg/kg to 2 mg/kg. For repeat dosing, daily doses of 8mg tramadol hydrochloride per kg body weight or 400mg tramadol hydrochloride, whichever is lower, should not be exceeded per day. The lowest analgesically effective dose should generally be selected.

On account of their high dosage strengths, capsules, prolonged release tablets and dispersible tablets are not intended for children below the age of 12 years.

Zydol is contraindicated

Zydol may only be used with particular caution in opioid-dependent patients, patients with head injury, shock, a reduced level of consciousness of uncertain origin, disorders of the respiratory centre or function, increased intracranial pressure.

In patients sensitive to opiates the product should only be used with caution.

Care should be taken when treating patients with respiratory depression, or if concomitant CNS depressant drugs are being administered (see section 4.5), or if the recommended dosage is significantly exceeded (see section 4.9) as the possibility of respiratory depression cannot be excluded in these situations.

Convulsions have been reported in patients receiving tramadol at the recommended dose levels. The risk may be increased when doses of tramadol exceed the recommended upper daily dose limit (400 mg). In addition, tramadol may increase the seizure risk in patients taking other medicinal products that lowers the seizure threshold (see section 4.5). Patients with epilepsy or those susceptible to seizures should be only treated with tramadol if there are compelling circumstances.

Tramadol has a low dependence potential. On long-term use tolerance, psychic and physical dependence may develop. In patients with a tendency to drug abuse or dependence, treatment with Zydol should only be carried out for short periods under strict medical supervision.

Tramadol is not suitable as a substitute in opioid-dependent patients. Although it is an opioid agonist, tramadol cannot suppress morphine withdrawal symptoms.

Zydol should not be combined with MAO inhibitors (see section 4.3).

In patients treated with MAO inhibitors in the 14 days prior to the use of the opioid pethidine, life-threatening interactions on the central nervous system, respiratory and cardiovascular function have been observed. The same interactions with MAO inhibitors cannot be ruled out during treatment with Zydol.

Concomitant administration of Zydol with other centrally depressant medicinal products including alcohol may potentiate the CNS effects (see section 4.8).

The results of pharmacokinetic studies have so far shown that on the concomitant or previous administration of cimetidine (enzyme inhibitor) clinically relevant interactions are unlikely to occur. Simultaneous or previous administration of carbamazepine (enzyme inducer) may reduce the analgesic effect and shorten the duration of action.

The combination with mixed agonist/antagonists (e.g. buprenorphine, nalbuphine, pentazocine) and tramadol is not advisable, because the analgesic effect of a pure agonist may be theoretically reduced in such circumstances.

Tramadol can induce convulsions and increase the potential for selective serotonin re-uptake inhibitors, tricyclic anti-depressants, anti-psychotics and other seizure threshold lowering medicinal products to cause convulsions.

In isolated cases there have been reports of serotonin syndrome in a temporal connection with the therapeutic use of tramadol in combination with other serotoninergic medicinal products such as selective serotonin re-uptake inhibitors (SSRIs) or with MAO inhibitors. Signs of serotonin syndrome may be for example confusion, agitation, fever, sweating, ataxia, hyperreflexia, myoclonus and diarrhoea. Withdrawal of the serotoninergic medicinal products usually brings about a rapid improvement. Treatment depends on the nature and severity of the symptoms.

Caution should be exercised during concomitant treatment with tramadol and coumarin derivatives (e.g. warfarin) due to reports of increased INR with major bleeding and ecchymoses in some patients.

Other active substances known to inhibit CYP3A4, such as ketoconazole and erythromycin, might inhibit the metabolism of tramadol (N-demethylation) probably also the metabolism of the active O-demethylated metabolite. The clinical importance of such an interaction has not been studied (see section 4.8).

In a limited number of studies the pre- or postoperative application of the antiemetic 5-HT3 antagonist ondansetron increased the requirement of tramadol in patients with postoperative pain.

Animal studies with tramadol revealed at very high doses effects on organ development, ossification and neonatal mortality. Teratogenic effects were not observed. Tramadol crosses the placenta. There is inadequate evidence available on the safety of tramadol in human pregnancy. Therefore Zydol should not be used in pregnant women.

Tramadol - administered before or during birth - does not affect uterine contractility. In neonates it may induce changes in the respiratory rate which are usually not clinically relevant. Chronic use during pregnancy may lead to neonatal withdrawal symptoms. During lactation about 0.1 % of the maternal dose is secreted into the milk. Zydol is not recommended during breast-feeding. After a single administration of tramadol it is not usually necessary to interrupt breast- feeding.

Even when taken according to instructions, Zydol may cause effects such as somnolence and dizziness and therefore may impair the reactions of drivers and machine operators. This applies particularly in conjunction with alcohol and other psychotropic substances.

Rapid intravenous administration may be associated with a higher incidence of adverse events and therefore should be avoided.

The most commonly reported adverse reactions are nausea and dizziness, both occurring in more than 10 % of patients.

The frequencies are defined as follows:

Very common:1/10

Common:1/100, <1/10

Uncommon:1/1000, <1/100

Rare:1/10 000, <1/1000

Very rare: <1/10 000

Not known: cannot be estimated from the available data

Cardiovascular disorders:

uncommon: cardiovascular regulation (palpitation, tachycardia, postural hypotension or cardiovascular collapse). These adverse reactions may occur especially on intravenous administration and in patients who are physically stressed.

rare: bradycardia, increase in blood pressure

Nervous system disorders:

very common: dizziness

common: headache, somnolence

rare: changes in appetite, paraesthesia, tremor, respiratory depression, epileptiform convulsions, involuntary muscle contractions, abnormal coordination, syncope.

If the recommended doses are considerably exceeded and other centrally depressant substances are administered concomitantly (see section 4.5), respiratory depression may occur.

Epileptiform convulsions occurred mainly after administration of high doses of tramadol or after concomitant treatment with medicinal products which can lower the seizure threshold (see sections 4.4 and 4.5).

not known: speech disorders

Psychiatric disorders:

rare: hallucinations, confusion, sleep disturbance, anxiety and nightmares. Psychic adverse reactions may occur following administration of Zydol, which vary individually in intensity and nature (depending on personality and duration of treatment). These include changes in mood (usually elation, occasionally dysphoria), changes in activity (usually suppression, occasionally increase) and changes in cognitive and sensorial capacity (e.g. decision behaviour, perception disorders). Dependence may occur.

Eye disorders:

rare: blurred vision

not known: mydriasis

Respiratory disorders:

rare:dyspnoea

Worsening of asthma has been reported, though a causal relationship has not been established.

Gastrointestinal disorders:

very common: nausea

common: vomiting, constipation, dry mouth

uncommon: retching, gastrointestinal irritation (a feeling of pressure in the stomach, bloating), diarrhoea

Skin and subcutaneous disorders:

common: sweating

uncommon: dermal reactions (e.g. pruritus, rash, urticaria)

Musculoskeletal disorders:

rare: motorial weakness

Hepatobiliary disorders:

In a few isolated cases an increase in liver enzyme values has been reported in a temporal connection with the therapeutic use of tramadol.

Renal and urinary disorders:

rare: micturition disorders (difficulty in passing urine, dysuria and urinary retention)

General disorders:

common: fatigue

rare: allergic reactions (e.g. dyspnoea, bronchospasm, wheezing, angioneurotic oedema) and anaphylaxis; symptoms of withdrawal reactions, similar to those occurring during opiate withdrawal, may occur as follows: agitation, anxiety, nervousness, insomnia, hyperkinesia, tremor and gastrointestinal symptoms. Other symptoms that have very rarely been seen with tramadol discontinuation include: panic attacks, severe anxiety, hallucinations, paraesthesias, tinnitus and unusual CNS symptoms (i.e. confusion, delusions, depersonalisation, derealisation, paranoia).

Symptoms

In principle, on intoxication with tramadol symptoms similar to those of other centrally acting analgesics (opioids) are to be expected. These include in particular miosis, vomiting, cardiovascular collapse, consciousness disorders up to coma, convulsions and respiratory depression up to respiratory arrest.

Treatment

The general emergency measures apply. Keep open the respiratory tract (aspiration!), maintain respiration and circulation depending on the symptoms. The antidote for respiratory depression is naloxone. In animal experiments naloxone had no effect on convulsions. In such cases diazepam should be given intravenously.

In case of intoxication orally, gastrointestinal decontamination with activated charcoal or by gastric lavage is only recommended within 2 hours after tramadol intake. Gastrointestinal decontamination at a later time point may be useful in case of intoxication with exceptionally large quantities.

Tramadol is minimally eliminated from the serum by haemodialysis or haemofiltration. Therefore treatment of acute intoxication with Zydol with haemodialysis or haemofiltration alone is not suitable for detoxification.

Pharmacotherapeutic group: other opioids; ATC-code N 02 AX 02

Tramadol is a centrally acting opioid analgesic. It is a non selective pure agonist at μ, δ and κ opioid receptors with a higher affinity for the μ receptor. Other mechanisms which contribute to its analgesic effect are inhibition of neuronal reuptake of noradrenaline and enhancement of serotonin release.

Tramadol has an antitussive effect. In contrast to morphine, analgesic doses of tramadol over a wide range have no respiratory depressant effect. Also gastrointestinal motility is less affected. Effects on the cardiovascular system tend to be slight. The potency of tramadol is reported to be 1/10 (one tenth) to 1/6 (one sixth) that of morphine.

After intramuscular administration in humans, tramadol is absorbed rapidly and completely: the mean peak serum concentration (C_max) is reached after 45 minutes and bioavailability is almost 100%.

The half-life of the terminal elimination phase (t_½β) was 6.0 + 1.5 h in young volunteers. Tramadol pharmacokinetics show little age dependence, the minimal changes being therapeutically irrelevant. In patients above the age of 65 years, the t_½β was 6.5 + 1.7 h on oral administration. In volunteers aged over 75 years, t_½β was 7.0 + 1.6 h on oral administration.

Since tramadol is eliminated both metabolically and renally, the terminal half-life t_½β may be prolonged in impaired hepatic or renal function. However, the increase in the t_½β values is relatively low if at least one of these organs is functioning normally. In patients with liver cirrhosis t_½β, tramadol was a mean of 13.3 + 4.9 h; in patients with renal insufficiency (creatinine clearance < 5ml/min) it was 11.0 + 3.2 h.

On repeated oral and parenteral administration of tramadol for 6 - 26 weeks in rats and dogs and oral administration for 12 months in dogs haematological, clinico-chemical and histological investigations showed no evidence of any substance-related changes. Central nervous manifestations only occurred after high doses considerably above the therapeutic range: restlessness, salivation, convulsions, and reduced weight gain. Rats and dogs tolerated oral doses of 20 mg/kg and 10 mg/kg body weight respectively, and dogs rectal doses of 20 mg/kg body weight without any reactions.

In rats tramadol dosages from 50 mg/kg/day upwards caused toxic effects in dams and raised neonate mortality. In the offspring retardation occurred in the form of ossification disorders and delayed vaginal and eye opening. Male fertility was not affected. After higher doses (from 50 mg/kg/day upwards) females exhibited a reduced pregnancy rate. In rabbits there were toxic effects in dams from 125 mg/kg upwards and skeletal anomalies in the offspring.

In some in-vitro test systems there was evidence of mutagenic effects. In-vivo studies showed no such effects. According to knowledge gained so far, tramadol can be classified as non-mutagenic.

Studies on the tumorigenic potential of tramadol hydrochloride have been carried out in rats and mice. The study in rats showed no evidence of any substance-related increase in the incidence of tumours. In the study in mice there was an increased incidence of liver cell adenomas in male animals (a dose-dependent, non-significant increase from 15 mg/kg upwards) and an increase in pulmonary tumours in females of all dosage groups (significant, but not dose-dependent).

Water for Injections

Sodium acetate

Precipitation will occur if Zydol injection is mixed in the same syringe with injections of diazepam, diclofenac, indometacin, phenylbutazone, midazolam, piroxicam and isoxicam.

Zydol ampoules have a shelf life of 5 years (unopened). Once opened, Zydol should be used immediately and any unused portions should be discarded.

Do not store above 30^oC

Store in the original container.

Clear Type I glass ampoules in boxes of 5 ampoules, each containing 2 ml solution.

Zydol solution for injection is physically and chemically compatible for up to 24 hours with 4.2% sodium bicarbonate and Ringer's solution and for up to 5 days with the following infusion solutions.

0.9% sodium chloride

0.18% sodium chloride and 4% glucose

sodium lactate compound

5% glucose

Haemaccel

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

Grünenthal Ltd.,

Regus Lakeside House

1 Furzeground Way

Stockley Park East

Uxbridge

Middlesex UB11 1BD

United Kingdom

PA 1189/1/4

May 2010