Normulen

Normulen 75 is indicated for patients who require the non-steroidal anti-inflammatory drug diclofenac together with misoprostol.

The diclofenac component of Normulen 75 is indicated for the symptomatic treatment of osteoarthritis and rheumatoid arthritis. The misoprostol component of Normulen 75 is indicated for patients with a special need for the prophylaxis of NSAID-induced gastric and duodenal ulceration.

Posology

Adults

One tablet to be taken with food, two times daily. Tablets should be swallowed whole, not chewed.

Elderly/renal, cardiac and hepatic impairment

No adjustment of dosage is necessary in the elderly or in patients with hepatic impairment or mild to moderate renal impairment as pharmacokinetics are not altered to any clinically relevant extent. Nevertheless, elderly patients and patients with renal, cardiac or hepatic impairment should be closely monitored.

Paediatric population

The safety and efficacy of Normulen 75 in children under 18 years has not been established.

Normulen 75 is contraindicated in:

- Patients with active peptic ulcer/haemorrhage or perforation or who have active GI bleeding or other active bleedings e.g. cerebrovascular bleedings.

- Pregnant women and in women planning a pregnancy.

- Patients with a known hypersensitivity to diclofenac, acetylsalicylic acid, other NSAIDs, misoprostol, other prostaglandins, or any other ingredient of the product.

- Patients in whom, attacks of asthma, urticaria or acute rhinitis are precipitated by acetylsalicylic acid or other non-steroidal anti-inflammatory agents.

- Treatment of peri-operative pain in the setting of coronary artery bypass graft (CABG) surgery.

- Patients with severe renal and hepatic failure.

- Established congestive heart failure (NYHA II-IV), ischemic heart disease, peripheral arterial disease and/or cerebrovascular disease.

Warnings

The use of diclofenac/misoprostol with concomitant systemic NSAIDs including COX-2 inhibitors should be avoided, except for patients requiring low dose acetylsalicylic acid - caution is advised in such patients with close monitoring. Concomitant use of a systemic NSAID and another NSAID may increase frequency of gastrointestinal ulcers and bleeding.

Normulen 75 should not be used in pre-menopausal women unless they use effective contraception and have been advised of the risks of taking the product if pregnant.

The label will state: 'Not for use in pre-menopausal women unless using effective contraception'.

Precautions

- Renal/cardiac/hepatic impairment

In patients with renal, cardiac or hepatic impairment and in the elderly, caution is required since the use of NSAIDs may result in deterioration of renal function. In the following conditions Normulen 75 should be used only in exceptional circumstances and with close clinical monitoring: advanced liver disease, severe dehydration.

In a large trial where patients received diclofenac for a mean of 18 months, ALT/AST elevations were observed in 3.1% of patients. ALT/AST elevations usually occur within 1-6 months. In clinical trials, hepatitis has been observed in patients who received diclofenac, and in postmarketing experience, other hepatic reactions have been reported, including jaundice and hepatic failure. During diclofenac/misoprostol therapy, liver function should be monitored periodically. If diclofenac/misoprostol is used in the presence of impaired liver function, close monitoring is necessary. If abnormal liver tests persist or worsen, if clinical signs and symptoms consistent with liver disease develop, or if systemic manifestations occur, treatment with diclofenac should be discontinued.

Diclofenac metabolites are eliminated primarily by the kidneys. The extent to which the metabolites may accumulate in patients with renal failure has not been studied. As with other NSAIDs, metabolites of which are excreted by the kidney, patients with significantly impaired renal function should be more closely monitored.

In rare cases, NSAIDs, including diclofenac/misoprostol, may cause interstitial nephritis, glomerulitis, papillary necrosis and the nephrotic syndrome. NSAIDs inhibit the synthesis of renal prostaglandin which plays a supportive role in the maintenance of renal perfusion in patients whose renal blood flow and blood volume are decreased. In these patients, administration of an NSAID may precipitate overt renal decompensation, which is typically followed by recovery to pretreatment state upon discontinuation of NSAID therapy. Patients at greatest risk of such a reaction are those with congestive heart failure, liver cirrhosis, nephrotic syndrome overt renal disease and the elderly. Such patients should be carefully monitored while receiving NSAID therapy.

Appropriate monitoring and advice are required for patients with a history of hypertension and/or mild to moderate congestive heart failure as fluid retention and oedema have been reported in association with NSAID therapy.

As with all NSAIDS, diclofenac/misoprostol can lead to the onset of new hypertension or worsening of pre-existing hypertension, either of which may contribute to the increased incidence of cardiovascular events. NSAIDs, including diclofenac/misoprostol, should be used with caution in patients with hypertension. Blood pressure should be monitored closely during the initiation of therapy with diclofenac/misoprostol and throughout the course of therapy.

Patients with significant risk factors for cardiovascular events (e.g. hypertension, hyperlipidaemia, diabetes mellitus, smoking) should only be treated with diclofenac after careful consideration. As the cardiovascular risks of diclofenac may increase with dose and duration of exposure, the shortest duration possible and the lowest effective daily dose should be used. The patient's need for symptomatic relief and response to therapy should be re-evaluated periodically.

Clinical trial and epidemiological data suggest that use of diclofenac, particularly at high dose (150mg daily) and in long term treatment may be associated with a small increased risk of serious arterial thrombotic events (for example myocardial infarction or stroke).

Physicians and patients should remain alert for the development of such events, even in the absence of previous cardiovascular symptoms. Patients should be informed about the signs and/or symptoms of serious cardiovascular toxicity and the steps to take if they occur.

- Blood system/gastrointestinal

NSAIDs, including diclofenac/misoprostol, can cause serious gastrointestinal (GI) adverse events including inflammation, bleeding, ulceration, and perforation of the stomach, small intestine, or large intestine, which can be fatal. When GI bleeding or ulceration occurs in patients receiving diclofenac/misoprostol, the treatment should be withdrawn. These events can occur at any time during treatment, with or without warning symptoms or in patients with a previous history of serious GI events.

Patients most at risk of developing these types of GI complications with NSAIDs are those treated at higher doses, the elderly, patients with cardiovascular disease, patients using concomitant acetylsalicylic acid, corticosteroids, selective serotonin reuptake inhibitors, patients who consume alcohol or patients with a prior history of, or active, gastrointestinal disease, such as ulceration, GI bleeding or inflammatory conditions.

Therefore, diclofenac/misoprostol should be used with caution in these patients and commence on treatment at the lowest dose available.

Patients with a history of GI toxicity, particularly when elderly, should report any unusual abdominal symptoms (especially GI bleeding) particularly in the initial stages of treatment. Caution should be advised in patients receiving concomitant medicines which could increase the risk of ulceration or bleeding, such as oral corticosteroids, , selective serotonin-reuptake inhibitors or anti-platelet agents such as aspirin. The concomitant use of NSAIDs, including Normulen 75, with oral anticoagulants increases the risk of GI and non-GI bleeding and should be given with caution. Oral anticoagulants include warfarin/coumarin-type and novel oral anticoagulants (e.g. apixaban, dabigatran, rivaroxaban). Anticoagulation/INR should be monitored in patients taking a warfarin/coumarin-type anticoagulant.

Normulen 75 in common with other NSAIDs, may decrease platelet aggregation and prolong bleeding time. Extra supervision is recommended in haematopoietic disorders or in conditions with defective coagulation or in patients with a history of cerebrovascular bleeding.

Caution is required in patients suffering from ulcerative colitis or Crohn's Disease as these conditions may be exacerbated.

Care should be taken in elderly patients and in patients treated with corticosteroids, other NSAIDs, or anti-coagulants.

- Skin reactions

Serious skin reactions, some of them fatal, including exfoliative dermatitis, Stevens-Johnson syndrome, and toxic epidermal necrolysis, have been reported very rarely in association with the use of NSAIDs, including diclofenac/misoprostol. Patients appear to be at highest risk for these events early in the course of therapy, the onset of the event occurring in the majority of cases within the first month of treatment. Diclofenac/misoprostol should be discontinued at the first appearance of skin rash, mucosal lesions, or any other sign of hypersensitivity.

- Hypersensitivity

NSAIDs may precipitate bronchospasm in patients suffering from, or with a history of bronchial asthma or allergic disease.

- Long-term treatment

All patients who are receiving long-term treatment with NSAIDs should be monitored as a precautionary measure (e.g. renal, hepatic function and blood counts). During long-term, high dose treatment with analgesic/anti-inflammatory drugs, headaches can occur which must not be treated with higher doses of the medicinal product.

- Normulen may mask fever and thus an underlying infection.

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

Patients who experience dizziness or other central nervous system disturbances while taking NSAIDs should refrain from driving or operating machinery.

In the table below the incidence of adverse drug reactions reported in controlled clinical studies where Normulen was administered to more than 2000 patients are listed. Additionally, adverse drug reactions reported during post-marketing surviellance are whose frequency cannot be estimated from the available data, such as spontaneous reports, have been listed at frequency 'unknown'. The most commonly observed adverse events are gastrointestinal in nature. In general, the adverse event profile of diclofenac/misoprostol in patients 65 years of age and older (556 subjects) was similar to that of younger patients (1564 subjects). The only clinically relevant differences were that patients 65 years of age and older appeared to be less tolerant to the gastrointestinal effects of diclofenac/misoprostol given three times a day.

¹ Symptoms of aseptic meningitis (stiff neck, headache, nausea, vomiting, fever or impaired consciousness) have been reported during treatment with NSAIDs. Patients suffering from autoimmune disease (e.g. lupus erythematosus, mixed connective tissue disorders) seem to be more susceptible.

² Diarrhoea is usually mild to moderate and transient and can be minimised by taking Normulen 75 with food and by avoiding the use of predominantly magnesium-containing antacids.

³ GI perforation or bleeding can sometimes be fatal, particularly in the elderly.

⁴ Serious skin reactions, some of them fatal, have been reported very rarely.

⁵ Especially in patients with hypertension or impaired renal function.

Given the lack of precise and/or reliable denominator and numerator figures, the spontaneous adverse event reporting system through which post marketing safety data are collected does not allow for a medically meaningful frequency of occurrence of any undesirable effects.

With regard to the relative frequency of reporting of adverse reactions during post marketing surveillance, the undesirable effects at the gastrointestinal level were those received most frequently by the MAH (approximately 45% of all case reports in the company safety database) followed by cutaneous/hypersensitivity-type reactions, which is in agreement with the known side effects profile of the NSAIDs drug class.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorization of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.

The toxic dose of Normulen 75 has not been determined and there is no experience of overdosage. Intensification of the pharmacological effects may occur with overdosage.

Symptoms

Clinical signs that may indicate misoprostol overdose are sedation, tremor, convulsions, dyspnoea, abdominal pain, diarrhoea, fever, palpitations, hypotension, or bradycardia.

Management

Management of acute poisoning with NSAIDs essentially consists of supportive and symptomatic measures. It is reasonable to take measures to reduce absorption of any recently consumed drug by forced emesis, gastric lavage or activated charcoal. Induced diuresis may be beneficial because diclofenac and misoprostol metabolites are excreted in the urine, provided that the patient does not develop renal failure at diclofenac overdose. Special measures such as haemodialysis or haemoperfusion are probably unlikely to be helpful in accelerating the elimination of diclofenac and misoprostol, due to the high protein binding and extensive metabolism.

Pharmacotherapeutic group (ATC code): M01AB55

Normulen 75 is a non-steroidal, anti-inflammatory drug, which is effective in treating the signs and symptoms of arthritic conditions.

This activity is due to the presence of diclofenac, which has been shown to have anti-inflammatory and analgesic properties.

Normulen 75 also contains the gastroduodenal mucosal protective component misoprostol, which is a synthetic prostaglandin E₁ analogue that enhances several of the factors that maintain gastroduodenal mucosal integrity.

Normulen 75 administered bd provides 200 micrograms less misoprostol than Normulen tds, whilst providing the same daily dose (150 mg) of diclofenac and may offer a better therapeutic ratio for certain patients.

The pharmacokinetic profiles following oral administration of a single dose or multiple doses of diclofenac sodium and misoprostol administered as Normulen 75 are similar to the profiles when the two drugs are administered as separate tablets. There are no pharmacokinetic interactions between the two components, apart from a slight decrease in diclofenac sodium Cmax when administered concomitantly with misoprostol.

Diclofenac sodium is completely absorbed from the gastrointestinal (GI) tract after fasting oral administration. Only 50 % of the absorbed dose is systemically available due to first pass metabolism. Peak plasma levels are achieved in 2 hours (range 1-4 hours), when given as a single dose under fasting conditions. Under fed conditions diclofenac Tmax is increased to 4 hours. The area-under-the plasma-concentration curve (AUC) is dose proportional within the range of 25 mg to 150 mg. The steady state absorption of diclofenac is reduced following the administration of Normulen 75 tablets with food, Cmax and AUC are reduced by approximately 40% and 20%, respectively.

The terminal half-life is approximately 2 hours. Clearance and volume of distribution are about 350 ml/min and 550 ml/kg, respectively. More than 99 % of diclofenac sodium is reversibly bound to human plasma albumin, and this has been shown not to be age dependent. Diclofenac metabolism is predominantly mediated via cytochrome P450 CYP2C9 in the liver. Patients who are known or suspected to be poor CYP2C9 metabolizers based on previous history/experience with other CYP2C9 substrates should be administered diclofenac with caution as they may have abnormally high plasma levels due to reduced metabolic clearance.

Diclofenac sodium is eliminated through metabolism and subsequent urinary and biliary excretion of the glucuronide and the sulfate conjugates of the metabolites. Approximately 65 % of the dose is excreted in the urine and 35 % in the bile. Less than 1 % of the parent drug is excreted unchanged.

Misoprostol is rapidly and extensively absorbed, and it undergoes rapid metabolism to its active metabolite, misoprostol acid, which is eliminated with an elimination t_½ of about 30 minutes. No accumulation of misoprostol acid was found in multiple-dose studies, and plasma steady state was achieved within 2 days. The serum protein binding of misoprostol acid is less than 90 %. Approximately 70 % of the administered dose is excreted in the urine, mainly as biologically inactive metabolites.

Single and multiple dose studies have been conducted comparing the pharmacokinetics of Normulen 75 with the diclofenac 75 mg and misoprostol 200 micrograms components administered separately. Bioequivalence between the two methods of providing diclofenac were demonstrable for AUC and absorption rate (C_max/AUC). In the steady state comparisons under fasted conditions bioequivalence was demonstrable in terms of AUC. Food reduced the rate and extent of absorption of diclofenac for both Normulen 75 and co-administered diclofenac. Despite the virtually identical mean AUCs in the fed, steady state, statistical bioequivalence was not established. This however is due to the broad co-efficients of variation in these studies due to the wide inter-individual variability in time to absorption and the extensive first-pass metabolism that occurs with diclofenac.

Bioequivalence in terms of AUC (0-24 h) was demonstrable when comparing steady state pharmacokinetics of Normulen 75 given bd with diclofenac 50 mg/misoprostol 200 micrograms given tds, both regimens providing a total daily dose of 150 mg diclofenac.

With respect to administration of misoprostol, bioequivalence was demonstrated after a single dose of Normulen 75 or misoprostol administered alone. Under steady state conditions food decreases the misoprostol C_max after Normulen 75 administration and slightly delays absorption, but the AUC is equivalent.

In co-administration studies in animals, the addition of misoprostol did not enhance the toxic effects of diclofenac. The combination was also shown not to be teratogenic or mutagenic. The individual components show no evidence of carcinogenic potential.

Misoprostol in multiples of the recommended therapeutic dose in animals has produced gastric mucosal hyperplasia. This characteristic response to E-series prostaglandins reverts to normal on discontinuation of the compound.

Not applicable.

No special requirements.