Roche Products (Ireland) Ltd

Lexotan 1.5 mg Tablets

Lexotan 3 mg Tablets

Lexotan 1.5 mg Tablets:

Each tablet contains 1.5 mg bromazepam

Excipients: Also contains 96.1 mg lactose monohydrate.

Lexotan 3 mg Tablets:

Each tablet contains 3 mg bromazepam.

Excipients: Also contains 94.4 mg lactose monohydrate.

For a full list of excipients, see section 6.1

Lexotan 1.5 mg Tablets:

Tablet

Off-white to slightly yellow, cylindrical, biplane tablets scored on one side and marked Roche 1.5 on reverse.

Lexotan 3 mg Tablets:

Tablet

Pale red, slightly speckled, cylindrical, biplane tablets scored on one side and marked Roche 3 on reverse.

The tablets can be divided into equal halves.

Anxiety

Benzodiazepines are only indicated when the disorder is severe, disabling or subjecting the individual to extreme distress.

Anxiety

Treatment should be as short as possible. The overall duration of treatment generally should not be more than 8 – 12 weeks, including tapering off process.

These amounts are general recommendations, and dosage should be individually determined. Treatment of outpatients should begin with low doses, gradually increasing to the optimum level. The patient should be reassessed regularly and the need for continued treatment should be evaluated, especially in case the patient is symptom free.

In certain cases, extension beyond the maximum treatment period may be necessary; if so, it should not take place without re-evaluation of the patient's status with special expertise.

Adults

The lowest dose which can control symptoms should be used.

The optimum dosage and frequency of administration of Lexotan should be based on the individual patient, the severity of symptoms and previous psychotropic drug history.

The usual dosage in general practice is from 3 mg to 18 mg daily in divided doses.

In exceptional circumstances, in hospitalised patients, up to the maximum daily dosage of 60 mg in divided doses, may be given.

Treatment should always be tapered off gradually. Patients who have taken benzodiazepines for a prolonged time may require a longer period during which doses are reduced. Specialist help may be appropriate.

Elderly and/or debilitated patients

Elderly patients require lower doses because of individual variations in sensitivity and pharmacokinetics; doses should not exceed half those normally recommended (see section 5.2).

Patients with impaired hepatic and/or renal function require lower doses because of individual variations in sensitivity and pharmacokinetics.

With the elderly and patients with impaired renal and/or hepatic function, it is advisable to review treatment regularly and to discontinue use as soon as possible.

Children

Lexotan is not for use in children less than 12 years of age.

Myasthenia gravis

Hypersensitivity to benzodiazepines

Severe respiratory insufficiency

Sleep apnoea syndrome

Severe hepatic insufficiency (benzodiazepines are not indicated to treat patients with severe hepatic insufficiency as they may cause encephalopathy)

General precautions

Concomitant use of alcohol / CNS depressants:

The concomitant use of Lexotan with alcohol or/and CNS depressants should be avoided. Such concomitant use has the potential to increase the clinical effects of Lexotan possibly including severe sedation, clinically relevant respiratory and/or cardio-vascular depression (see section 4.5).

Medical history of alcohol or drug abuse:

Lexotan should be used with extreme caution in patients with a medical history of alcohol or drug abuse.

Patients should be checked regularly at the start of treatment in order to minimize the dosage and/or the frequency of administration and to prevent overdose due to accumulation.

Tolerance

Some loss of efficacy to the effects of Lexotan may develop after repeated use for a few weeks.

Dependence

Use of benzodiazepines and benzodiazepine-like agents may lead to the development of physical and psychic dependence upon these products, (see section 4.8). The risk of dependence increases with dose and duration of treatment; it is also greater in patients with a medical history of alcohol and/or drug abuse.

Once physical dependence has developed, abrupt termination of treatment will be accompanied by withdrawal symptoms. These may consist of headaches, muscle pain, extreme anxiety, tension, restlessness, confusion and irritability. In severe cases the following symptoms may occur: derealisation, depersonalisation, hyperacusis, numbness and tingling of the extremities, hypersensitivity to light, noise and physical contact, hallucinations or epileptic seizures, (see section 4.8).

Rebound insomnia and anxiety: a transient syndrome whereby the symptoms that led to treatment with a benzodiazepine recur in an enhanced form, may occur on withdrawal of treatment. It may be accompanied by other reactions including mood changes, anxiety or sleep disturbances and restlessness. Since the risk of withdrawal phenomena/rebound phenomena is greater after abrupt discontinuation of treatment, it is recommended that the dosage is decreased gradually.

Duration of treatment

The duration of treatment should be as short as possible (see section 4.2). The overall duration of treatment generally should not be more than 8 – 12 weeks, including a tapering off process. Extension beyond these periods should not take place without re-evaluation of the situation.

It may be useful to inform the patient when treatment is started that it will be of limited duration and to explain precisely how the dosage will be progressively decreased. Moreover it is important that the patient should be aware of the possibility of rebound phenomena, thereby minimising anxiety over such symptoms should they occur while the medicinal product is being discontinued.

There are indications that, in the case of benzodiazepines with a short duration of action, withdrawal phenomena can become manifest within the dosage interval, especially when the dosage is high. When benzodiazepines with a long duration of action are being used it is important to warn against changing to a benzodiazepine with a short duration of action, as withdrawal symptoms may develop.

Amnesia

It should be borne in mind that benzodiazepines may induce anterograde amnesia. Anterograde amnesia may occur using higher therapeutic dosages (documented at 6mg), the risk increasing at higher dosages. Amnestic effects may be associated with inappropriate behaviour. The condition occurs most often several hours after ingesting the product and therefore to reduce the risk patients should ensure that they will be able to have an uninterrupted sleep of 7 – 8 hours (see section 4.8).

Psychiatric and “paradoxical” reactions

Reactions like restlessness, agitation, irritability, aggressiveness, delusion, rages, nightmares, hallucinations, psychoses, inappropriate behaviour and other adverse behavioural effects are known to occur when using benzodiazepines. Should this occur, use of the drug should be discontinued.

They are more likely to occur in children and the elderly.

Specific patient groups

Benzodiazepines should not be given to children without careful assessment of the need to do so; the duration of treatment must be kept to a minimum. Elderly should be given a reduced dose (see section 4.2). Due to the myorelaxant effect of benzodiazepines, the risk of falls and consequently of hip fractures in elderly patients is increased. A lower dose is also recommended for patients with chronic respiratory insufficiency due to the risk of respiratory depression. Benzodiazepines are not indicated to treat patients with severe hepatic insufficiency as they may precipitate encephalopathy.

Benzodiazepines are not recommended for the primary treatment of psychotic illness.

Benzodiazepines should not be used alone to treat depression or anxiety associated with depression (suicide may be precipitated in such patients).

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

Pharmacokinetic Drug-Drug Interaction (DDI)

Compounds which inhibit certain hepatic enzymes (particularly cytochrome P450) may enhance the activity of those benzodiazepines that are metabolised by these enzymes. To a lesser degree this also applies to benzodiazepines that are metabolised only by conjugation.

Co-administration of cimetidine may prolong the elimination half-life of bromazepam.

Pharmacodynamic Drug-Drug Interaction (DDI)

Enhanced effects on sedation, respiration and hemodynamics may occur when Lexotan is co-administered with any centrally acting depressants including alcohol.

Alcohol should be avoided in patients receiving Lexotan (see section 4.4).

(See section 4.9) Overdose for warnings of other central nervous system depressants, including alcohol.

In the case of narcotic analgesics, enhancement of the euphoria may also occur leading to an increase in psychic drug dependence.

Benzodiazepines should only be used during pregnancy or lactation if considered essential by the physician. Animal studies with benzodiazepines have shown minor effects on the foetus while a few studies have reported a late behavioural disturbance in offspring exposed in utero.

If the product is prescribed to a woman of childbearing potential, she should be warned to contact her physician regarding discontinuance of the product if she intends to become or suspects that she is pregnant.

If, for compelling medical reasons, the product is administered during the late phase of pregnancy, or during labour, effects on the neonate, such as hypothermia, hypotonia and moderate respiratory depression, can be expected, due to the pharmacological action of the compound.

Moreover, infants born to mothers who took benzodiazepines chronically during the latter stages of pregnancy may have developed physical dependence and may be at some risk for developing withdrawal symptoms in the post-natal period.

Since benzodiazepines are found in the breast milk, benzodiazepines should not be given to breast feeding mothers.

Sedation, amnesia, impaired concentration and impaired muscular function may adversely affect the ability to drive or to use machines. If insufficient sleep duration occurs, the likelihood of impaired alertness may be increased (see section 4.5 Interaction with other medicaments and other forms of interaction). Patients should further be advised that alcohol may intensify any impairment, and should, therefore, be avoided during treatment.

Lexotan is well tolerated in therapeutic doses. The following undesirable effects may occur:

Psychiatric Disorders:

Confusional state, emotional disorder. These phenomena occur predominantly at the start of therapy and usually disappear with repeated administration. Libido disorders have been reported occasionally.

Depression: Pre-existing depression may be unmasked during benzodiazepine use.

Paradoxical reactions such as restlessness, agitation, irritability, aggression, delusion, anger, nightmares, hallucinations, psychosis, inappropriate behaviour and other adverse behavioural effects are known to occur with benzodiazepines or benzodiazepine-like agents (see section 4.4). Should this occur, the use of the drug should be discontinued. They are more likely to occur in children and elderly patients than in other patients.

Dependence: Chronic use (even therapeutic doses) may lead to the development of physical and psychic drug dependence: discontinuation of therapy may result in withdrawal or rebound phenomena (see section 4.4)

Abuse of benzodiazepines has been reported.

Nervous System Disorder: Drowsiness, headache, dizziness, decreased alertness, ataxia. These phenomena occur predominantly at the start of therapy and usually disappear with repeated administration. Anterograde amnesia may occur using therapeutic dosages, the risk increasing at higher dosages. Amnestic effects may be associated with inappropriate behaviour.

Eye Disorders: Diplopia, this phenomenon occurs predominantly at the start of therapy and usually disappears with repeated administration.

Gastrointestinal Disorders: Gastrointestinal disorders have been reported occasionally.

Skin and Subcutaneous Tissue Disorders: Skin reactions have been reported occasionally.

Musculoskeletal and Connective Tissue Disorders: Muscle weakness, this phenomenon occurs predominantly at the start of therapy and usually disappears with repeated administration.

General Disorders and Administration Site Conditions: Fatigue, this phenomenon occurs predominantly at the start of therapy and usually disappears with repeated administration.

Injury, Poisoning and Procedural Complications: An increased risk for falls and fractures has been reported in elderly benzodiazepine users.

Respiratory Disorders: Respiratory depression.

Cardiac Disorders: Cardiac failure including cardiac arrest.

Symptoms

Benzodiazepines commonly cause drowsiness, ataxia, dysarthria and nystagmus. Overdose of Lexotan is seldom life-threatening if the drug is taken alone, but may lead to areflexia, apnea, hypotension, cardiorespiratory depression and coma. Coma, if it occurs, usually lasts a few hours but it may be more protracted and cyclical, particularly in elderly patients. Benzodiazepine respiratory depressant effects are more serious in patients with respiratory disease.

Benzodiazepines increase the effects of other central nervous system depressants, including alcohol.

Treatment

Monitor the patient's vital signs and institute supportive measures as indicated by the patient's clinical state. In particular, patients may require symptomatic treatment for cardiorespiratory effects or central nervous system effects.

Further absorption should be prevented using an appropriate method e.g. treatment within 1-2 hours with activated charcoal. If activated charcoal is used airway protection is imperative for drowsy patients. In case of mixed ingestion gastric lavage may be considered, however not as a routine measure

If CNS depression is severe consider the use of flumazenil (Anexate^®), a benzodiazepine antagonist. This should only be administered under closely monitored conditions. It has a short half-life (about an hour), therefore patients administered flumazenil will require monitoring after its effects have worn off. Flumazenil is to be used with extreme caution in the presence of drugs that reduce seizure threshold (e.g. tricyclic antidepressants). Refer to the prescribing information for flumazenil (Anexate^®), for further information on the correct use of this drug.

Bromazepam is a pyridylbenzodiazepine compound with anxiolytic properties.

Absorption

Lexotan is rapidly absorbed from the gastro-intestinal tract. Peak plasma concentrations are usually reached within 2 hours of oral administration of bromazepam. The absolute (versus i.v. solution) and relative (versus oral solution) bioavailability of the tablet is 60% and 100% respectively.

Distribution

On average, 70% of bromazepam is bound to plasma proteins. The volume of distribution is 50 litres. Steady state plasma concentrations are reached in around 5 – 9 days.

Metabolism

Bromazepam is metabolised in the liver. Quantitatively, two metabolites predominate: 3-hydroxy-bromazepam and 2-(2-amino-5-bromo-3-hydroxybenzoyl) pyridine. Metabolites of Lexotan do not contribute significantly to the effects of the drug.

Elimination

The urinary recovery of intact bromazepam and the glucuronide conjugates of 3-hydroxy-bromazepam and 2-(2-amino-5-bromo-3-hydroxybenzoyl) pyridine is 2%, 27% and 40% of the administered dose. Bromazepam has an elimination half-life of about 20 hours (between approximately 16 and 30 hours). The clearance is 40ml/min.

Pharmacokinetics in special populations

The elimination half-life may be prolonged in elderly patients (see section 4.2 Posology and method of administration).

Carcinogenicity

Carcinogenicity studies conducted in rats did not reveal any evidence of a carcinogenic potential for bromazepam.

Mutagenicity

Bromazepam was not genotoxic in in-vitro and in-vivo tests.

Impairment of Fertility

Daily oral administration of bromazepam did not have any affect on the fertility and general reproductive performance of rats.

Teratogenicity

Increases in foetal mortality, an increase in the stillbirth rate and a reduction in pup survival have been observed when bromazepam was given to pregnant rats. In studies on embryotoxicity/teratogenicity no teratogenic effect was detected up to a dosage of 125 mg/kg/day.

Following per os administration with doses of up to 50 mg/kg/day to pregnant rabbits a reduction in maternal weight gain, a reduction in foetal weight and an increase in the incidence of resorptions have been observed.

Other

Chronic toxicity

No deviations from normal were observed in long-term toxicology studies except for an increase in liver weight. Histopathological examination revealed centrolobular hepatocellular hypertrophy which was considered to be indicative of enzyme induction by bromazepam. Adverse effects observed after high doses were slight to moderate sedation, ataxia, isolated brief convulsive seizures, occasional elevation in serum alkaline phosphatase and a borderline increase in SGPT (ALT).

Lexotan 1.5 mg Tablets:

Microcrystalline cellulose

Lactose monohydrate

Magnesium stearate

Talc

Lexotan 3 mg Tablets:

Microcrystalline cellulose

Lactose monohydrate

Magnesium stearate

Talc

Iron oxide red (E172)

Not applicable.

PVDC blister packs: 5 year shelf life.

HDPE bottles: 5 year shelf life.

PVC blister packs: 5 year shelf life.

Do not store above 25°C. Store in the original package in order to protect from light and moisture.

PVDC blister packs of 4, 10, 20, 60 or 100 tablets.

HDPE bottles of 100 tablets.

PVC blister packs of 30 tablets.

Not all pack sizes may be marketed

No special requirements.

Roche Products Limited

6 Falcon Way, Shire Park

Welwyn Garden City

AL7 1TW

United Kingdom

Lexotan 1.5 mg Tablets: PA 50/49/1

Lexotan 3 mg Tablets: PA 50/49/2

Date of first authorization: 31 October 1980

Date of last renewal: 31 October 2010

November 2010

Further information is available from Roche Products (Ireland) Limited, 30004 Lake Drive, City West, Naas Road, Dublin 24.

Lexotan is a registered trade mark Item code