Nurofen Double Strength is indicated for the temporary relief of pain and/or inflammation associated with headache, migraine headache, tension headache, sinus pain, toothache, dental procedures, backache, muscular aches and pains, period pain, sore throat, tennis elbow, arthritis, rheumatic pain and the aches and pains associated with colds and flu. Reduces fever. 

The lowest effective dose should be used for the shortest duration necessary to relieve symptoms (see section 4.4).
• Dosage:
Adults and Children 12 years & over: One tablet to be taken with or without food. If necessary, repeat every 4-6 hours 
Pregnancy: see Section 4.3 Contraindications and Section 4.6 Fertility, pregnancy and lactation. 
Not recommended for children under 12. 
• Maximum tolerated daily dose:
Maximum 3 tablets in 24 hours. Nurofen Double Strength should not be used for more than 3 days a time, except on medical advice, in which case the patient should be reviewed regularly with regards to efficacy, risk factors and ongoing need for treatment.
• Monitoring advice
If symptoms persist, please consult your healthcare professional.

Nurofen Double Strength is contraindicated for use in patients with: • known hypersensitivity or idiosyncratic reaction to ibuprofen (or any of the other ingredients in the product) • known hypersensitivity to aspirin and other NSAIDs • asthma that is aspirin or NSAID sensitive • active gastrointestinal bleeding or peptic ulceration • renal impairment • heart failure • severe liver impairment • undergoing treatment of perioperative pain in setting of coronary artery bypass surgery (CABG) Use of Nurofen Double Strength is contraindicated during the third trimester of pregnancy. Nurofen Double Strength should not be taken with other medicines containing ibuprofen, aspirin or other anti-inflammatory medicines or other medicines being taken regularly unless under medical advice. Refer to ‘Interactions with other medicines’ for additional information.

Identified precautions
Undesirable effects may be minimised by using the minimum effective dose for the shortest duration necessary to control symptoms. Nurofen Double Strength should not be used for more than 3 days at a time except on medical advice. Treatment should be immediately discontinued at the first appearance of cutaneous reactions or relevant gastrointestinal events. 
Nurofen Double Strength should not be taken with other medicines containing ibuprofen, aspirin or other anti-inflammatory medicines or other medicines being taken regularly unless under medical advice. 
Gastrointestinal (GI) 
NSAIDS should be given with care to patients with a history of gastrointestinal disease (ulcerative colitis, Crohn's disease) as their condition may be exacerbated (See Adverse effects). 
Gastrointestinal GI bleeding, ulceration and perforation which can be fatal, have been reported with all NSAIDs at any time during treatment, with or without warning symptoms or a previous history of serious GI events. The frequency of such events may increase with dose or duration of use. Patients at most risk of developing these types of GI complications with NSAIDs are the elderly, patients using concomitant aspirin, patients with a history of, or active GI disease (e.g. ulceration, GI bleeding or inflammatory conditions) and patients with a history of smoking and alcoholism. 

Nurofen 400mg Double Strength should be used only under medical advice in:

- Patients with previous history of GI haemorrhage or ulcers (see also Contraindications – active GI bleeding or peptic ulceration). Patients should report any new or unusual abdominal symptoms during treatment. If GI bleeding or ulceration occurs in patients receiving Nurofen Double Strength, the treatment should be withdrawn immediately. Appropriate clinical evaluation and treatment should be considered.

- Patients receiving concomitant medications which could increase the risk of ulceration or bleeding, such as oral corticosteroids, anticoagulants such as warfarin, selective serotonin- reuptake inhibitors or anti-platelet agents such as aspirin or other NSAIDs including cyclooxygenase-2 (COX-2) selective inhibitors. 

Cardiovascular and cerebrovascular effects 
Observational studies have indicated that NSAIDs may be associated with an increased risk of serious cardiovascular events, including myocardial infarction and stroke, which may increase with dose or duration of use. Patients with cardiovascular disease, history of atherosclerotic cardiovascular disease or cardiovascular risk factors may also be at greater risk. 
Clinical trial and epidemiological data suggest that the use of ibuprofen, particularly at high doses (2400 mg daily) and in long term treatment may be associated with a small increased risk of arterial thrombotic events (for example myocardial infarction or stroke). Overall, epidemiological studies do not suggest that low dose ibuprofen (e.g. ≤ 1200 mg daily) is associated with an increased risk of myocardial infarction. 
Cases of Kounis syndrome have been reported in patients treated with ibuprofen-containing products such as Nurofen Double Strength. Kounis syndrome has been defined as cardiovascular symptoms secondary to an allergic or hypersensitive reaction associated with constriction of coronary arteries and potentially leading to myocardial infarction. 
Patients should be advised to remain alert for such cardiovascular events, even in the absence of previous cardiovascular symptoms. Patients should be informed about signs and/or symptoms of serious cardiovascular toxicity and the steps to take if they occur. 
Fluid retention, hypertension and oedema have been reported in association with NSAID therapy. Patients taking antihypertensives with NSAIDs may have an impaired antihypertensive response. 
Nurofen Double Strength should only be used under medical advice in patients with hypertension (see also contraindications – heart failure). 

Renal
Renal impairment as renal function may deteriorate

Use in hepatic impairment
As with other NSAIDs elevations of one or more liver function tests may occur in up to 15% of patients. These abnormalities may progress, may remain essentially unchanged or may resolve with continued therapy. Meaningful elevations (three times the upper limit of normal) of ALT or AST occurred in controlled clinical trials in less than 1% of patients. 
Ibuprofen has been reported to have a minor and transient effect on liver enzymes. Therefore, NUROFEN DOUBLE STRENGTH should be used with caution in patients with hepatic dysfunction. 
Patients should be advised to remain alert for hepatotoxicity and be informed about the signs and/or symptoms of hepatotoxicity (e.g. nausea, fatigue, lethargy, pruritus, jaundice, abdominal tenderness in the right upper quadrant and “flu-like” symptoms). 

Respiratory
Nurofen Double Strength should be used only under medical advice in patients with, or a previous history of, bronchial asthma or allergic disease because bronchospasm may be precipitated in these patients. 

SLE and mixed connective tissue disease 
Nurofen Double Strength should be used with caution in patients with systemic lupus erythematosus and mixed connective tissue disease as there is a risk of increased aseptic meningitis 

Skin and Subcutaneous Tissue Disorders
Severe cutaneous adverse reactions (SCARs)
Dermatological effects: Severe cutaneous adverse reactions (SCARs), including exfoliative dermatitis, erythema multiforme, Stevens-Johnson syndrome (SJS), Drug Reaction with Eosinophilia with Systemic Symptoms (see DRESS), toxic epidermal necrolysis, and acute generalised exanthematous pustulosis (AGEP), which can be life-threatening or fatal, have been  reported in association with the use of ibuprofen (see Adverse Effects). Most of these reactions occurred within the first month. If signs and symptoms suggestive of these reactions appear, Nurofen Double Strength should be withdrawn immediately, and an alternative treatment considered (as appropriate).  

Severe skin reactions such as acute generalised exanthematous pustulosis (AGEP) may occur with ibuprofen- containing products. The acute pustular eruption may occur within the first 2 days of treatment, with fever, and numerous, small, mostly non- follicular pustules arising on a widespread oedematous erythema and mainly localised on the skin folds, trunk and upper extremities. Patients should be carefully monitored. If signs and symptoms such as pyrexia, erythema, or many small pustules are observed, administration of Nurofen Double Strength should be discontinued, and appropriate measures taken if needed. 

Drug Reaction with Eosinophilia with Systemic Symptoms (DRESS)
DRESS has been reported in patients using NSAIDs. Some of these events have been fatal or life- threatening. DRESS typically, although not exclusively, presents with fever, rash, lymphadenopathy, and/or facial swelling. Other clinical manifestations may include hepatitis, nephritis, haematological abnormalities, myocarditis, or myositis. Sometimes symptoms of DRESS may resemble an acute viral infection. Eosinophilia is often present. Because this disorder is variable in its presentation, other organ systems not noted here may be involved. It is important to note that early manifestations of hypersensitivity, such as fever or lymphadenopathy, may be present even though rash is not evident. If such signs or symptoms are present, discontinue the NSAID and evaluate the patient immediately.

Masking of symptoms of underlying infections
Nurofen Double Strength can mask symptoms of infection. This has been observed in bacterial community acquired pneumonia and bacterial complications to varicella. When Nurofen Double strength is administered for fever or pain relief in relation infection, monitoring of infection is advised. In non- hospital settings the patient should consult a doctor if symptoms persist or worsen

Refer to ‘Interactions with other medicines’ for additional information. 
Use in the elderly
Ibuprofen should not be taken by adults over the age of 65 without careful consideration of co- morbidities and co-medications because of an increased risk of adverse effects, in particular heart failure, gastro-intestinal ulceration and renal impairment (see also Contraindications –renal impairment, heart failure). 

Paediatric use
Nurofen DOUBLE STRENGTH is recommended for adults and children from 12 years old. No investigations have been carried out with this product in children under 12 years of age.
Nurofen for Children products are available for paediatric use. 

Effects on laboratory tests
No information is available regarding Nurofen Double Strength and laboratory tests. 

Product specific special warnings 
Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrose-isomaltase insufficiency should not take this medicine

Ibuprofen (like other NSAIDs) should be avoided in combination with: 
• Aspirin: Experimental data suggest that ibuprofen may inhibit the effect of low dose aspirin on platelet aggregation when they are dosed concomitantly. However, no clinically relevant effect is considered to be likely for occasional ibuprofen use.
• Other NSAIDs including aspirin and cyclooxygenase-2-selective inhibitors: avoid the use of two or more NSAIDS as this may increase the risk of adverse effects

The following interactions with ibuprofen have been noted: 

• Anticoagulants, including warfarin – ibuprofen interferes with the stability of INR and may increase risk of severe bleeding and sometimes fatal haemorrhage, especially from the gastrointestinal tract. Ibuprofen should only be used in patients taking warfarin if absolutely necessary and they must be closely monitored.
• ACE inhibitors, diuretics and other antihypertensives: Ibuprofen can reduce the antihypertensive effect of antiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists and beta-blockers with possible loss of blood pressure control and hyperkalaemia. Ibuprofen may reduce the antihypertensive and natriuretic effect of diuretics. Diuretics can increase the risk of nephrotoxicity of NSAIDs. The combined use of the three classes of drugs, diuretics, an ACE inhibiting drug (ACE inhibitor or angiotensin receptor antagonist) and an anti-inflammatory drug (NSAID or cyclooxygenase-2 (COX-2) inhibitor) all at the same time increases the risk of renal impairment. The combination of drugs from these three classes should be used with caution particularly in elderly patients. In some patients with compromised renal function (e.g. dehydrated patients or elderly patients with compromised renal function) the co-administration of an ACE inhibitor or Angiotensin II antagonist and agents that inhibit cyclo-oxygenase may result in further deterioration of renal function, including possible acute renal failure, which is usually reversible. These interactions should be considered in patients taking a NSAID concomitantly with ACE inhibitors or angiotensin II antagonists.
• Anti-platelet agents and selective serotonin reuptake inhibitors (SSRIs): increased risk of gastrointestinal bleeding
• Ciclosporin: Increased risk of nephrotoxicity.
• Cardiac glycosides: Ibuprofen may exacerbate cardiac failure, reduce glomerular filtration rate (GFR) and increase plasma glycoside levels.
• Cyclosporin: increased risk of nephrotoxicity.
• Corticosteroids: Ibuprofen may increase the risk of gastrointestinal ulceration or bleeding especially if taken with corticosteroids.
• Lithium: Ibuprofen may decrease renal clearance and increase plasma concentration of lithium.
• Methotrexate: There is potential for an increase in plasma levels of methotrexate.
Ibuprofen reduces methotrexate clearance.
• Mifepristone: NSAIDs should not be used for 8-12 days after mifepristone administration as NSAIDs can reduce the effect of mifepristone.
• Quinolone antibiotics: Animal data indicate that NSAIDs can increase the risk of convulsions associated with Quinolone antibiotics. Patients taking NSAIDs and quinolones may have an increased risk of developing convulsions. 
• Tacrolimus: possible increased risk of nephrotoxicity when NSAIDs are given with tacrolimus.
• Zidovudine: Increased risk of haematological toxicity when NSAIDs are given with Zidovudine. There is evidence of an increased risk of haemarthroses and haematomain HIV (+) haemophiliacs receiving concurrent treatment with Zidovudine and ibuprofen. 

Ibuprofen may also interact with probenecid, antidiabetic medicines and phenytoin.

Effects on fertility
The use of ibuprofen may impair female fertility and is not recommended in women attempting to conceive. In women who have difficulties conceiving or who are undergoing investigation of infertility, withdrawal of ibuprofen should be considered. 
Use in pregnancy
Category C: Inhibition of prostaglandin synthesis by ibuprofen may adversely affect pregnancy and/or the embryo/foetal development. During the first and second trimester of pregnancy, this product should not be given unless clearly necessary, and is contraindicated in the third trimester.
During the third trimester, all prostaglandin synthesis inhibitors may expose the foetus to cardiopulmonary toxicity (with premature closure of the ductus arteriosus and pulmonary hypertension) and renal dysfunction, which may progress to renal failure with oligohydramnios. At the end of pregnancy, prostaglandin synthesis inhibitors may expose the mother and the neonate to possible prolongation of bleeding time and inhibition of uterine contractions, which may result in delayed or prolonged labour.

Oligohydramnios and Neonatal Renal Impairment
Use of NSAIDs from about 20 weeks gestation may cause neonatal renal dysfunction leading to oligohydramnios and, in some cases, neonatal renal impairment. 
These adverse outcomes are seen, on average, after days to weeks of treatment, although oligohydramnios has been infrequently reported as soon as 48 hours after NSAID initiation. Oligohydramnios is often, but not always, reversible with treatment discontinuation.
Complications of prolonged oligohydramnios may, for example, include limb contractures and delayed lung maturation. In some post-marketing cases of impaired neonatal renal function, invasive procedures such as exchange transfusion or dialysis were required.If, after careful consideration of alternative treatment options for pain management, NSAID treatment is necessary from about 20 weeks, limit use to the lowest effective dose and shortest duration possible. Consider ultrasound monitoring of amniotic fluid if treatment extends beyond 48 hours. Discontinue treatment with NSAIDs if oligohydramnios occurs. 

Use in lactation. 
Ibuprofen appears in breast milk in very low concentrations and is unlikely to affect the breast fed infant adversely. 

The effects of this medicine on a person's ability to drive and use machines were not assessed as part of its registration.

The frequencies of adverse effects are defined as follows: 
Very common: >1/10 
Common: >1/100, <1/10 
Uncommon: >1/1,000, <1/100 
Rare: >1/10,000, <1/1,000 
Very Rare: <1/10,000, including isolated reports. 
Hypersensitivity reactions have been reported following treatment with ibuprofen. These may consist of 
a) Non-specific allergic reactions and anaphylaxis 
b) Respiratory tract reactivity e.g. asthma, aggravated asthma, bronchospasm, dyspnea. 
c) Assorted skin disorders, including rashes of various types, pruritius, urticaria, purpura, angioedema and more rarely bullous dermatoses (including epidermal necrolysis and erythema multiforme)

The following adverse effects relates to those experienced with ibuprofen at OTC doses, for short-term use. In the treatment of chronic conditions, under long term treatment, additional adverse effects may occur. 

Blood and Lymphatic System Disorders: 
Very rare: Haematopoietic disorders (anaemia, leucopenia, thrombocytopenia, pancytopenia and agranulocytosis). 

Hypersensitivity reactions: 
Uncommon: Hypersensitivity reactions with urticaria and pruritius 
Very rare: severe hypersensitivity reactions. Symptoms could be facial, tongue and larynx, swelling, dyspnoea, apnoea, tachycardia, hypotension, (anaphylaxis, angioedema or severe shock - syndrome may be characterised by abdominal pain, fever, shivering, nausea and vomiting. Exacerbation of asthma and bronchospasm. 
Hepatotoxicity and aseptic meningitis which occur less frequently may also be hypersensitivity reactions. 
Allergic reactions such as skin rash, itching, swelling of the face or breathing difficulties are usually transient and reversible on cessation of treatment. 

Gastrointestinal disorders: 
The most commonly observed adverse events are gastrointestinal in nature. 
Uncommon: abdominal pain, nausea, dyspepsia 
Rare: Diarrhoea, flatulence, heartburn, loss of appetite, constipation and vomiting 
Very rare: peptic ulcer, perforation or gastrointestinal haemorrhage, melaena, haematemesis, sometimes fatal, particularly in the elderly. Ulcerative stomatitis, gastritis. 
Unknown: Exacerbation of ulcerative colitis and Crohn's, disease, Gastric pyrosis. 

Nervous System: 
Uncommon: Headache 
Very rare: Aseptic meningitis - single cases have been reported, Dizziness, nervousness, tinnitus, depression, drowsiness, insomnia, irritability, difficulty in concentrating, emotional instability, convulsions, auditory and visual problems. 
Rare: fatigue 

Renal: 
Very rare: Acute renal failure, papillary necrosis, especially in long-term use, associated with increased serum urea and oedema. 

Ibuprofen may cause cystitis and haematuria, interstitial nephritis, nephrotic syndrome, oliguria, tubular necrosis, glomerulonephritis, alteration in the renal function test, polyuria. 

Liver: 
Very rare: liver disorders, especially in long term treatment, including hepatotoxicity, hepatitis, jaundice, alterations of hepatic function tests, pancreatitis, duodenitis, oesophagitis, hepato-renal syndrome, hepatic necrosis, hepatic insufficiency. 

Haematological: 
Very rare: Haematopoietic disorders (anaemia, neutropenia, aplastic anaemia, haemolytic anaemia, eosinophilia, reduction of haemoglobin and haematocrit leucopenia,thrombocytopenia, pancytopenia, agranulocytosis). Reversible platelet aggregation, alveolitis, pulmonary eosinophilia, pancreatitis. 

Skin and Subcutaneous Tissue Disorders: 
Uncommon: Various skin rashes 
Very rare: Severe cutaneous adverse reactions (SCARs) such as bullous reactions including Stevens Johnson Syndrome, erythema multiform, exfoliative dermatitis and toxic epidermal necrolysis can occur. Rarely skin peeling, alopecia, exfoliative dermatitis, photosensitive dermatitis, maculopapular, Rash. 
Unknown: Drug Reaction with Eosinophilia with Systemic Symptoms (DRESS), Acute generalized exanthematous pustulosis (AGEP), photosensitivity reactions 

Immune System: 
In patients with existing auto-immune disorders (such as systemic lupus erythematosus, mixed connective tissue disease) during treatment with ibuprofen, single cases of symptoms of aseptic meningitis, such as stiff neck, headache, nausea, vomiting, fever or disorientation have been observed. 

Cardiovascular and Cerebrovascular: 
Oedema, hypertension, and cardiac failure have been reported in association with NSAID treatment. 
Clinical trial and epidemiological data suggest that use of ibuprofen (particularly at high doses 2400mg daily) and in long-term treatment may be associated with a small increased risk of arterial thrombotic events (for example myocardial infarction or stroke). 
Rarely: cerebrovascular accidents, hypotension, congestive cardiac insufficiency in patients with compromised cardiac function, palpitations. 
Not known: Kounis syndrome 

Ocular: 
Very rare: Blurred vision, changes in visual colour perception, toxic amblyopia, episodes of cular alteration with consequent visual disorders.

Pregnancy, puerperium and perinatal conditions: 
Unknown: Oligohydramnios, neonatal renal impairment 

Other: 
Effect on the endocrine system and on the metabolism, reduction in appetite. 
Rarely: dryness of the eyes and mouth, gingival ulcers, rhinitis, hearing disturbances.

Reporting suspected adverse effects
Reporting suspected adverse reactions after registration 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 at www.tga.gov.au/reporting-problems. 

In case of overdose, immediately contact the Poisons Information Centre (in Australia, call 13 11 26; in New Zealand call 0800 764 766) for advice. 
In adults the dose response effect is less clear cut than in children where ingestion of more than 400mg/kg may cause symptoms. The half- life in overdose is 1.5-3 hours. 

Symptoms: Most patients who have ingested clinically important amounts of NSAIDs will develop no more than nausea, vomiting, epigastric pain, or more rarely diarrhoea. Tinnitus, headache and gastrointestinal bleeding are also possible. In more serious poisoning, toxicity is seen in the central nervous system, manifesting as vertigo, drowsiness, occasionally excitation and disorientation or coma. Occasionally patients develop convulsions. In serious poisoning hyperkalaemia and metabolic acidosis may occur and the prothrombin time/INR may be prolonged, probably due to interference with the actions of circulating clotting factors. Acute renal failure, liver damage, hypotension, respiratory depression and cyanosis may occur. Exacerbation of asthma is possible in asthmatics. 

Management: Management should be symptomatic and supportive and include the maintenance of a clear airway and monitoring of cardiac and vital signs until stable. Consider oral administration of activated charcoal if the patient presents within 1 hour of ingestion of a  potentially toxic amount. If frequent or prolonged, convulsions should be treated with intravenous diazepam or lorazepam. Give bronchodilators for asthma. 

Mechanism of action
Ibuprofen possesses analgesic, antipyretic and anti-inflammatory properties, similar to other  non-steroidal anti-inflammatory drugs (NSAIDs). Its mechanism of action is unknown but is thought to be through peripheral inhibition of cyclooxygenases and subsequent prostaglandin synthetase inhibition.

Clinical trials
No data available.

Absorption
Ibuprofen is well absorbed after oral administration with peak serum levels occurring after 1 to 2 hours. 

Distribution
Apparent volume of distribution is 0.14L/kg. Ibuprofen and its metabolites readily cross the placental barrier in pregnant rabbits and rats. It is not known if the drug enters the
cerebrospinal fluid. 99% of ibuprofen is protein bound. The high protein binding of the drug should be borne in mind when prescribing ibuprofen together with other protein bound drugs that bind to the same site on human serum albumin.

Metabolism 
90% of ibuprofen is metabolised in the liver to produce two major metabolites, a hydroxylated and carboxylated compound. 

Excretion
Both the inactive metabolites and a small amount of unchanged ibuprofen are excreted rapidly and completely by the kidney with 95% of the administered dose eliminated in the urine within four hours of ingestion. The elimination half-life of ibuprofen is in the range 1.9 to 2.2 hours.

Genotoxicity
No information is available regarding Nurofen 400 Double Strength and genotoxicity. 
Carcinogenicity
No information is available regarding Nurofen 400 Double Strength and carcinogenicity. 

Nurofen DOUBLE STRENGTH tablets - Croscarmellose sodium, sodium lauryl sulfate, sodium citrate, stearic acid, colloidal anhydrous silica, carmellose sodium, purified-talc, acacia, sucrose, titanium dioxide, macrogol 6000, opacode monogramming ink S-1-15094 red

Incompatibilities were either not assessed or not identified as part of the registration of this medicine.

In Australia, information on the shelf life can be found on the public summary of the Australian Register of Therapeutic Goods (ARTG). The expiry date can be found on the packaging.

Store below 25°C 

Container type 
Nurofen Double Strength tablets are packed in an aluminium blister pack. 
Pack sizes 
Nurofen Double Strength tablets Packs of 8, 10, 12, 20, 24, 30, 36, 40, 48 and 50. (not all pack sizes may be marketed)

In Australia, any unused medicine or waste material should be disposed of by taking to your local pharmacy.