serotonin-system are considered an important factor in the development of depression and related diseases.

Zelax contains escitalopram and is used to treat depression (major depressive episodes) and anxiety disorders (such as panic disorder with or without agoraphobia, social anxiety disorder, generalised anxiety disorder and obsessive-compulsive disorder).

It may take a couple of weeks before you start to feel better. Continue to take Zelax, even if it takes some time before you feel any improvement in your condition.

You must talk to a doctor if you do not feel better or if you feel worse.

A. Do not take Zelax:

• If you are allergic to escitalopram or any of the other ingredients of this medicine (listed in section 6).

• If you take other medicines which belong to a group called MAO inhibitors, including selegiline (used in the treatment of Parkinson’s disease), moclobemide (used in the treatment of depression) and linezolid (an antibiotic).

• If you are born with or have had an episode of abnormal heart rhythm (seen at ECG; an examination to evaluate how the heart is functioning).

• If you take medicines for heart rhythm problems or that may affect the heart’s rhythm (see section 2 “Taking other medicines with Zelax”).

B. Take special care with Zelax:

Talk to your doctor or pharmacist before taking Zelax. Please tell your doctor if you have any other condition or illness, as your doctor may need to take this into consideration. In particular, tell your doctor:    

• If you have epilepsy. Treatment with Zelax should be stopped if seizures occur for the first time, or if there is an increase in the seizure frequency (see also section 4 “Possible side effects”).

• If you suffer from impaired liver or kidney function. Your doctor may need to adjust your dosage.

• If you have diabetes. Treatment with Zelax may alter glycaemic control. Insulin and/or oral hypoglycaemic dosage may need to be adjusted.

• If you have a decreased level of sodium in the blood.

• If you have a tendency to easily develop bleedings or bruises.

• If you are receiving electroconvulsive treatment.

• If you have coronary heart disease.

• If you suffer or have suffered from heart problems or have recently had a heart attack.

• If you have a low resting heart-rate and/or you know that you may have salt depletion as a result of prolonged severe diarrhoea and vomiting (being sick) or usage of diuretics (water tablets).

• If you experience a fast or irregular heart beat, fainting, collapse or dizziness on standing up, which may indicate abnormal functioning of the heart rate.

• If you have or have previously had eye problems, such as certain kinds of glaucoma (increased pressure in the eye).

Please note.

Some patients with manic-depressive illness may enter into a manic phase. This is characterized by unusual and rapidly changing ideas, inappropriate happiness and excessive physical activity. If you experience this, contact your doctor.

Symptoms such as restlessness or difficulty in sitting or standing still can also occur during the first weeks of the treatment. Tell your doctor immediately if you experience these symptoms.

Thoughts of suicide and worsening of your depression or anxiety disorder.

If you are depressed and/or have anxiety disorders you can sometimes have thoughts of harming or killing yourself. These may be increased when first starting antidepressants, since these medicines all take time to work, usually about two weeks but sometimes longer.

You may be more likely to think like this:

• If you have previously had thoughts about killing or harming yourself.

• If you are a young adult. Information from clinical trials has shown an increased risk of suicidal behaviour in adults aged less than 25 years with psychiatric conditions who were treated with an antidepressant.

If you have thoughts of harming or killing yourself at any time, contact your doctor or go to a hospital straight away.

You may find it helpful to tell a relative or close friend that you are depressed or have an anxiety disorder, and ask them to read this leaflet. You might ask them to tell you if they think your depression or anxiety is getting worse, or if they are worried about changes in your behaviour.

Children and adolescents:

Zelax should normally not be used for children and adolescents under 18 years. Also, you should know that patients under 18 have an increased risk of side effects such as suicide attempts, suicidal thoughts and hostility (predominately aggression, oppositional behaviour and anger) when they take this class of medicines. Despite this, your doctor may prescribe Zelax for patients under 18 because he/she decides that this is in their best interest. If your doctor has prescribed Zelax for a patient under 18 and you want to discuss this, please go back to your doctor.

You should inform your doctor if any symptoms listed above develop or worsen when patients under 18 are taking Zelax. Also, the long term safety effects concerning growth, maturation and cognitive and behavioural development of Zelax in this age group have not yet been demonstrated.

C. Taking other medicines with Zelax:

Tell your doctor or pharmacist if you are taking, have recently taken or might take any other medicines.

Tell your doctor if you are taking any of the following medicines:

• “Non-selective monoamine oxidase inhibitors (MAOIs)”, containing phenelzine, iproniazid, isocarboxazid, nialamide, and tranylcypromine as active ingredients. If you have taken any of these medicines you will need to wait 14 days before you start taking Zelax. After stopping Zelax you must allow 7 days before taking any of these medicines.

• “Reversible, selective MAO-A inhibitors”, containing moclobemide (used to treat depression).

• “Irreversible MAO-B inhibitors”, containing selegiline (used to treat Parkinson’s disease). These increase the risk of side effects.

• The antibiotic linezolid.

• Lithium (used in the treatment of manic-depressive disorder) and tryptophan.

• Imipramine and desipramine (both used to treat depression).

• Sumatriptan and similar medicines (used to treat migraine) and tramadol (used against severe pain). Increase the risk of side effects.

• Cimetidine, lansoprazole and omeprazole (used to treat stomach ulcers), fluvoxamine (antidepressant) and ticlopidine (used to reduce the risk of stroke). These may cause increased blood levels of escitalopram.

• St. John's wort (hypericum perforatum) - a herbal remedy used for depression.

• Acetylsalicylic acid (aspirin) and non-steroidal anti-inflammatory drugs (medicines used for pain relief or to thin the blood, so called anti-coagulant). These may increase bleeding-tendency.

• Warfarin, dipyridamole, and phenprocoumon (medicines used to thin the blood, so called anti-coagulant). Your doctor will probably check the coagulation time of your blood when starting and discontinuing Zelax in order to verify that your dose of anti-coagulant is still adequate.

• Mefloquine (used to treat Malaria), bupropion (used to treat depression) and tramadol (used to treat severe pain) due to a possible risk of a lowered threshold for seizures.

• Neuroleptics (medicines to treat schizophrenia, psychosis) and antidepressants (tricyclic antidepressants and SSRIs) due to a possible risk of a lowered threshold for seizures.

• Flecainide, propafenone, and metoprolol (used in cardiovascular diseases) clomipramine, and nortriptyline (antidepressants) and risperidone, thioridazine, and haloperidol (antipsychotics). The dosage of Zelax may need to be adjusted.

• Medicines that decrease blood levels of potassium or magnesium, as these conditions increase the risk of life-threatening heart rhythm disorders.

Do not take Zelax if you take medicines for heart rhythm problems or medicines that may affect the heart’s rhythm, such as Class IA and III antiarrhythmics, antipsychotics (e.g. phenothiazine derivatives, pimozide, haloperidol), tricyclic antidepressants, certain antimicrobial agents (e.g. sparfloxacin, moxifloxacin, erythromycin IV, pentamidine, anti-malarial treatment particularly halofantrine), certain antihistamines (e.g. astemizole, mizolastine). If you have any further questions about this you should speak to your doctor.

D. Taking Zelax with food and drink:

Zelax can be taken with or without food (see section 3 “How to take Zelax”).

As with many medicines, combining Zelax with alcohol is not advisable, although Zelax is not expected to interact with alcohol.

E. Pregnancy and breast-feeding and fertility:

Inform your doctor if you are pregnant or planning to become pregnant. Do not take Zelax if you are pregnant or breast-feeding, unless you and your doctor have discussed the risks and benefits involved.

If you take Zelax during the last 3 months of your pregnancy you should be aware that the following effects may be seen in your newborn baby: trouble with breathing, bluish skin, fits, body temperature changes, feeding difficulties, vomiting, low blood sugar, stiff or floppy muscles, vivid reflexes, tremor, jitteriness, irritability, lethargy, constant crying, sleepiness and sleeping difficulties. If your newborn baby has any of these symptoms, please contact your doctor immediately.

Make sure your midwife and/or doctor know you are on Zelax When taken during pregnancy, particularly in the last 3 months of pregnancy, medicines like Zelax may increase the risk of a serious condition in babies, called persistent pulmonary hypertension of the newborn (PPHN), making the baby breathe faster and appear bluish. These symptoms usually begin during the first 24 hours after the baby is born. If this happens to your baby you should contact your midwife and/or doctor immediately.

If used during pregnancy Zelax should never be stopped abruptly.

It is expected that Zelax will be excreted into breast milk.

Citalopram, a medicine like escitalopram, has been shown to reduce the quality of sperm in animal studies. Theoretically, this could affect fertility, but impact on human fertility has not been observed as yet.

F. Driving and using machines:

You are advised not to drive a car or operate machinery until you know how Zelax affects you.

G. Important information about some of the ingredients of Zelax:

None.

Always take this medicine exactly as your doctor has told you. Check with your doctor or pharmacist if you are not sure.

Adults:

Depression:

The normally recommended dose of Zelax is 10 mg taken as one daily dose. The dose may be increased by your doctor to a maximum of 20 mg per day.

Panic disorder:

The starting dose of Escitalopram is 5 mg as one daily dose for the first week before increasing the dose to 10 mg per day. The dose may be further increased by your doctor to a maximum of 20 mg per day.

Social anxiety disorder:

The normally recommended dose of Zelax is 10 mg taken as one daily dose. Your doctor can either decrease your dose to 5 mg per day or increase the dose to a maximum of 20 mg per day, depending on how you respond to the medicine.

Generalised anxiety disorder:

The normally recommended dose of Zelax is 10 mg taken as one daily dose. The dose may be increased by your doctor to a maximum of 20 mg per day.

Obsessive-compulsive disorder:

The normally recommended dose of Zelax is 10 mg taken as one daily dose. The dose may be increased by your doctor to a maximum of 20 mg per day.

Elderly patients (above 65 years of age):

The recommended starting dose of Escitalopram is 5 mg taken as one daily dose. The dose may be increased by your doctor to 10 mg per day.

Children and adolescents (below 18 years of age):

Zelax should not normally be given to children and adolescents. For further information please see section 2 “Before you take Zelax”.

You can take Zelax with or without food. Swallow the caplet with some water. Do not chew them, as the taste is bitter.

Duration of treatment:

It may take a couple of weeks before you start to feel better. Continue to take Zelax even if it takes some time before you feel any improvement in your condition.

Do not change the dose of your medicine without talking to your doctor first.

Continue to take Zelax for as long as your doctor recommends. If you stop your treatment too soon, your symptoms may return. It is recommended that treatment should be continued for at least 6 months after you feel well again.

A. If you take more Zelax than you should:

If you take more than the prescribed dose of Zelax, contact your doctor or nearest hospital emergency department immediately. Do this even if there are no signs of discomfort. Some of the signs of an overdose could be dizziness, tremor, agitation, convulsion, coma, nausea, vomiting, change in heart rhythm, decreased blood pressure and change in body fluid/salt balance. Take the Zelax box/container with you when you go to the doctor or hospital.

B. If you forget to take your Zelax:

Do not take a double dose to make up for forgotten doses. If you do forget to take a dose, and you remember before you go to bed, take it straight away. Carry on as usual the next day. If you only remember during the night, or the next day, leave out the missed dose and carry on as usual.

C. If you stop taking Zelax:

Do not stop taking Zelax until your doctor tells you to do so. When you have completed your course of treatment, it is generally advised that the dose of Zelax is gradually reduced over a number of weeks.

When you stop taking Zelax, especially if it is abruptly, you may feel discontinuation symptoms. These are common when treatment with Zelax is stopped. The risk is higher, when Zelax has been used for a long time or in high doses or when the dose is reduced too quickly. Most people find that the symptoms are mild and go away on their own within two weeks. However, in some patients they may be severe in intensity or they may be prolonged (2-3 months or more). If you get severe discontinuation symptoms when you stop taking Zelax, please contact your doctor. He or she may ask you to start taking your caplets again and come off them more slowly.

Discontinuation symptoms include: Feeling dizzy (unsteady or off-balance), feelings like pins and needles, burning sensations and (less commonly) electric shock sensations, including in the head, sleep disturbances (vivid dreams, nightmares, inability to sleep), feeling anxious, headaches, feeling sick (nausea), sweating (including night sweats), feeling restless or agitated, tremor (shakiness), feeling confused or disorientated, feeling emotional or irritable, diarrhoea (loose stools), visual disturbances, fluttering or pounding heartbeat (palpitations).

If you have any further questions on the use of this medicine, ask your doctor or pharmacist.

Like all medicines, this medicine can cause side effects, although not everybody gets them.

The side effects usually disappear after a few weeks of treatment. Please be aware that many of the effects may also be symptoms of your illness and therefore will improve when you start to get better.

If you experience any of the following symptoms you should contact your doctor or go to the hospital straight away:

Uncommon (may affect up to 1 in 100 people):

• Unusual bleeds, including gastrointestinal bleeds

Rare (may affect up to 1 in 1000 people):

• Swelling of skin, tongue, lips, or face, or have difficulties breathing or swallowing (allergic reaction).

• High fever, agitation, confusion, trembling and abrupt contractions of muscles these may be signs of a rare condition called serotonin syndrome.

Not known (frequency cannot be estimated from the available data):

• Difficulties urinating.

• Seizures (fits), see also section 2 “Take special care with Zelax”

• Yellowing of the skin and the white in the eyes are signs of liver function impairment/hepatitis

• Fast, irregular heartbeat, fainting which could be symptoms of a life-threatening condition known as torsade de pointes

• Thoughts of harming or killing yourself, see also section 2 “Take special care with Zelax”

In addition to the above the following side effects have been reported:

Very common (may affect more than 1 in 10 people):

• Feeling sick (nausea).

• Headache.

Common (may affect up to 1 in 10 people):

• Blocked or runny nose (sinusitis).

• Decreased or increased appetite.

• Anxiety, restlessness, abnormal dreams, difficulties falling asleep, feeling sleepy, dizziness, yawning, tremors, prickling of the skin.

• Diarrhoea, constipation, vomiting, dry mouth.

• Increased sweating.

• Pain in muscle and joints (arthralgia and myalgia).

• Sexual disturbances (delayed ejaculation, problems with erection, decreased sexual drive and women may experience difficulties achieving orgasm).

• Fatigue, fever.

• Increased weight .

Uncommon (may affect up to 1 in 100 people):

• Nettle rash (urticaria), rash, itching (pruritus).

• Grinding one’s teeth, agitation, nervousness, panic attack, confusion.

• Disturbed sleep, taste disturbance, fainting (syncope).

• Enlarged pupils (mydriasis), visual disturbance, ringing in the ears (tinnitus).

• Loss of hair.

• Excessive menstrual bleeding.

• Irregular menstrual period.

• Decreased weight.

• Fast heart beat.

• Swelling of the arms or legs.

• Nosebleeds.

Rare (may affect up to 1 in 1000 people):

• Aggression, depersonalisation, hallucination.

• Slow heart beat.

Not known (frequency cannot be estimated from the available data):

• Decreased levels of sodium in the blood (the symptoms are feeling: sick and unwell with weak muscles; or confused)

• Dizziness when you stand up due to low blood pressure (orthostatic hypotension)

• Abnormal liver function test (increased amounts of liver enzymes in the blood)

• Movement disorders (involuntary movements of the muscles)

• Painful erections (priapism).

• Signs of increased bleeding e.g. from skin and mucous membranes (ecchymosis).

• Sudden swelling of skin or mucosa (angioedemas).

• Increase in the amount of urine excreted (inappropriate ADH secretion).

• Flow of milk in men and in women that are not nursing.

• Mania.

• An increased risk of bone fractures has been observed in patients taking this type of medicine.

• Alteration of the heart rhythm (called “prolongation of QT interval”, seen on ECG, measuring electrical activity of the heart).

In addition, a number of side effects are known to occur with drugs that work in a similar way to escitalopram. These are:

• Motor restlessness (akathisia).

• Loss of appetite.

• Keep out of the reach and sight of children.

• Do not use Zelax after the expiry date which is stated on the label and carton.  

• This medicinal product does not require any special storage conditions.

• Do not use any Zelax pack that is damaged or shows signs of tampering.

• Store below 30oC.