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Fusidic acid is metabolised in the liver and excreted in the bile. Elevated liver enzymes and jaundice have occurred during Fucidin^®systemic therapy but are usually reversible on discontinuation of the drug.

Fucidin^®administered systemically should be given with caution and liver function should be monitored if used in patients with impaired liver function, in patients given potentially hepato- toxic drugs, and if used in patients with biliary tract obstruction or in patients on concurrent drugs with similar excretion pathway.

Fusidic acid competitively inhibits binding of bilirubin to albumin. Caution is necessary if Fucidin^®is administered systemically to patients with impaired transport and metabolism of bilirubin. Particular care should be taken in neonates (especially if premature) due to the theoretical risk of kernicterus.

Fucidin^® Suspension contains liquid glucose, sorbitol and orange dry flavour (theoretically which contains sucrose); patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase–isomaltase insufficiency should not take this medicine.

Fucidin^® Suspension contains 2 mg sodium per ml; this should be taken into consideration by patients on a controlled sodium diet.

Bacterial resistance has been reported to occur with the use of fusidic acid. As with all antibiotics, extended or recurrent use may increase the risk of developing antibiotic resistance.

4.5 Interaction with other medicinal products and other forms of interaction

HMG-CoA reductase inhibitors

Co-administration of Fucidin^® systemically and HMG-CoA reductase inhibitors (statins) causes increased plasma concentrations of both agents resulting in an elevation of creatine kinase level (rhabdomyolysis), muscle weakness and pain. Concomitant treatment with statins is therefore contraindicated, see section 4.3.

CYP-3A4 biotransformed drugs

Specific pathways of Fucidin^® metabolism in the liver are not known, however, an interaction between Fucidin^® and drugs being CYP-3A4 biotransformed can be suspected. The mechanism of this interaction is presumed to be a mutual inhibition of metabolism. The use of Fucidin^® systemically should be avoided in patients treated with CYP-3A4 biotransformed drugs.

Oral anticoagulants

Fucidin^® administered systemically and concomitantly with oral anticoagulants such as coumarin derivatives or anticoagulants with similar action may increase the plasma concentration of these agents enhancing the anticoagulant effect. Adjustment of the oral anticoagulant dose may be necessary in order to maintain the desired level of anticoagulation. The mechanism of this suspected interaction remains unknown.

HIV protease inhibitors

Co-administration of Fucidin^® systemically and HIV protease inhibitors such as Ritonavir and Saquinavir causes increased plasma concentrations of both agents which may result in hepatotoxicity.

Ciclosporin

Co-administration of Fucidin^® systemically and Ciclosporin has been reported to cause increased plasma concentration of Ciclosporin.

4.6 Pregnancy and lactation

Pregnancy

There are no adequate data from the use of fusidic acid administered systemically in pregnant women. Animal studies are insufficient with respect to effects on pregnancy. The potential risk for humans is unknown. Fucidin^® administered systemically should not be used during pregnancy unless clearly necessary.

Lactation

Fusidic acid is excreted in breast milk in negligible amounts. The clinical relevance of this is unknown. Caution is therefore required when Fucidin^®is used in mothers who wish to breast feed.

4.7 Effects on ability to drive and use machines

Fusidic acid has no or negligible influence on the ability to drive and to use machines.

4.8 Undesirable effects

Very common	>1/10
Common	>1/100 and <1/10
Uncommon	>1/1,000 and <1/100
Rare	>1/10,000 and <1/1,000
Very rare	<1/10,000

Based on clinical data for the indication skin and subcutaneous tissue infection, undesirable effects occurred in approximately 5% of children receiving Fucidin^® oral suspension. Gastrointestinal system disorders are dose dependant.

The most frequently reported undesirable effects to Fucidin^® administered orally are gastrointestinal disorders and symptoms of general disorders. Various skin reactions, reversible jaundice, haematological disorders and generalised hypersensitivity reactions have been reported.

Blood and lymphatic system disorders

Very rare:

Pancytopenia

Leukopenia*

Thrombocytopenia

Anaemia

* Haematological disorders affecting the white cell line (neutropenia, granulocytopenia, agranulocytosis) and more rarely disorders affecting the other two cell lines have been reported, either as isolated events or together. This has been observed especially in cases of treatment with duration of more than 15 days and is reversible upon drug withdrawal.

Immune system disorders

Rare:

Allergic reaction

Very rare:

Anaphylactic reaction

Metabolism and nutrition disorders

Uncommon:

Anorexia

Nervous system disorders

Uncommon:

Drowsiness

Gastrointestinal disorders

Common:

Diarrhoea

Vomiting

Abdominal pain

Dyspepsia

Nausea

Hepatobiliary disorders

Rare:

Hyperbilirubinaemia

Jaundice

Hepatic enzymes increased

Very rare:

Hepatorenal syndrome

Liver function abnormalities like hyperbilirubinaemia (with or without jaundice) and increase in hepatic enzymes such as alkaline phophatase and transaminases should lead to withdrawal of treatment. Return of laboratory parameters to normal is usual and generally rapid.

Hepatorenal syndrome, cf. 'Renal disorders'.

Skin and subcutaneous tissue disorders

Uncommon:

Rash*

Urticaria

Pruritus

*Rash includes various types of rash reactions such as erythematous, maculo-papular and pustular.

Renal and urinary disorders

Very rare:

Renal failure

Acute renal failure has been described in patients with jaundice, in particular in the presence of other factors predisposing for renal failure.

General disorders and application site conditions

Uncommon:

Asthenia

Fatigue

Malaise

Musculoskeletal, connective tissue and bone disorders

Frequency not known:

Rhabdomyolysis (examples of signs and symptoms are: muscle weakness, swelling and pain, dark urine, myoglobinuria, elevated serum creatine kinase, acute renal failure, cardiac arrhythmia), see section 4.5.

4.9 Overdose

Acute symptoms of overdose include gastrointestinal disturbances and possible effect on liver function. Management should be directed towards alleviation of symptoms. Dialysis will not increase the clearance of fusidic acid.

5. PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: General anti-infective for systemic use.

ATC code: J01XC01

Fucidin^® exerts powerful activity against a number of gram-positive organisms. Staphylococci, including the strains resistant to penicillin and other antibiotics, are particularly susceptible to Fucidin^®. Concentrations of 0.03 - 0.12 mcg/ml inhibit nearly all strains of Staphylococcus aureus.

5.2 Pharmacokinetic properties

Fucidin^® readily penetrates the central nervous system when the meninges are inflamed and is widely distributed in the body. Bactericidal levels have been assayed in bone and necrotic tissue. Blood levels are cumulative, reaching concentrations of 50-100 mcg/ml after oral administration of 1.5 g daily for three to four days. Fucidin^® is excreted mainly in the bile, little, or none being excreted in the urine.

5.3 Preclinical safety data

There are no preclinical data of relevance to the prescriber which are additional to that already included in other areas of the SPC.

6. PHARMACEUTICAL PARTICULARS

6.1 List of excipients

acesulfame potassium

banana flavour

citric acid monohydrate

disodium phosphate dihydrate (E339)

liquid glucose

hyetellose

methylcellulose

orange dry flavour (contains sucrose)