Levofloxacin Sandoz, 500 mg, film-coated tablets is indicated in adults for the treatment of the following infections (see sections 4.4 and 5.1):

• Acute pyelonephritis and complicated urinary tract infections (see section 4.4)
• Chronic bacterial prostatitis
• Inhalation Anthrax (postexposure prophylaxis and curative treatment (see section 4.4))

For the below-mentioned infections Levofloxacin Sandoz, 500 mg, film-coated tablets should be used only when it is considered inappropriate to use antibacterial agents that are commonly recommended for the treatment of these infections:

• Acute bacterial sinusitis
• Acute exacerbations of chronic obstructive pulmonary disease including bronchitis
• Community-acquired pneumonia
• Complicated skin and soft tissue infections
• Uncomplicated cystitis (see section 4.4)

Levofloxacin Sandoz, film-coated tablets may also be used to complete a course of therapy in patients who have shown improvement during initial treatment with intravenous levofloxacin.

Consideration should be given to official guidance on the appropriate use of antibacterial agents

Levofloxacin Sandoz, film-coated tablets are administered once or twice daily. The dosage depends on the type and severity of the infection and the susceptibility of the presumed causative pathogen.

Levofloxacin Sandoz, film-coated tablets may also be used to complete a course of therapy in patients who have shown improvement during initial treatment with intravenous levofloxacin; given the bioequivalence of the parenteral and oral forms, the same dosage can be used.

 

Posology

The following dose recommendations can be given for Levofloxacin Sandoz, film-coated tablets:

 

Dosage in patients with normal renal function

(creatinine clearance > 50 mL/min)

 

Indications	Daily dose regimen (according to severity)	Duration of treatment (according to severity)
Acute bacterial sinusitis	500 mg once daily	10-14 days
Acute bacterial exacerbations of chronic obstructive pulmonary disease including bronchitis	500 mg once daily	7-10 days
Community-acquired pneumonia	500 mg once or twice daily	7-14 days
Acute pyelonephritis	500 mg once daily	7-10 days
Complicated urinary tract infections	500 mg once daily	7-14 days
Uncomplicated cystitis	250 mg once daily	3 days
Chronic bacterial prostatitis	500 mg once daily	28 days
Complicated skin and soft tissue infections	500 mg once or twice daily	7-14 days
Inhalation Anthrax	500 mg once daily	8 weeks

 

Special populations

 

Patients with renal impairment

(creatinine clearance ≤ 50mL/min)

 

Dose regimen
	250 mg/24 h	500 mg/24 h	500 mg/12 h
Creatinine clearance	first dose: 250 mg	first dose: 500 mg	first dose: 500 mg
50-20 mL/min	then: 125 mg/24 h	then : 250 mg/24 h	then : 250 mg/12 h
19-10 mL/min	then: 125 mg/48 h	then : 125 mg/24 h	then : 125 mg/12 h
< 10 mL/min (including haemodialysis and CAPD)*	then: 125 mg/48 h	then: 125 mg/24 h	then: 125 mg/24 h

 

* No additional doses are required after haemodialysis or continuous ambulatory peritoneal dialysis (CAPD).

 

Patients with hepatic impairment

No adjustment of dose is required since levofloxacin is not metabolised to any relevant extent by the liver and is mainly excreted by the kidneys.

 

Elderly

No adjustment of dose is required in elderly, other than that imposed by consideration of renal function (See section 4.4 “Tendinitis and tendon rupture” and “QT interval prolongation”).

 

Paediatric population

Levofloxacin is contraindicated in children and growing adolescents (see section 4.3).

 

Method of administration

Levofloxacin Sandoz, film-coated tablets should be swallowed without crushing and with sufficient amount of liquid. They may be divided at the score line to adapt the dose. The tablets may be taken during meals or between meals. Levofloxacin Sandoz, film-coated tablets should be taken at least two hours before or after iron salts, zinc salts, magnesium- or aluminium-containing antacids, or didanosine (only didanosine formulations with aluminium or magnesium containing buffering agents), and sucralfate administration, since reduction of absorption can occur (see section 4.5).

Levofloxacin tablets must not be used: • in patients hypersensitive to levofloxacin or other quinolones or any of the excipients listed in section 6.1, • in patients with epilepsy, • in patients with history of tendon disorders related to fluoroquinolone administration, • in children or growing adolescents, • during pregnancy, • in breast-feeding women.

The use of levofloxacin should be avoided in patients who have experienced serious adverse reactions in the past when using quinolone or fluoroquinolone containing products (see section 4.8). Treatment of these patients with levofloxacin should only be initiated in the absence of alternative treatment options and after careful benefit/risk assessment (see also section 4.3).

Prolonged, disabling and potentially irreversible serious adverse drug reactions
Very rare cases of prolonged (continuing months or years), disabling and potentially irreversible serious adverse drug reactions affecting different, sometimes multiple, body systems (musculoskeletal, nervous, psychiatric and senses) have been reported in patients receiving quinolones and fluoroquinolones irrespective of their age and pre-existing risk factors. Levofloxacin should be discontinued immediately at the first signs or symptoms of any serious adverse reaction and patients should be advised to contact their prescriber for advice.

Methicillin-resistant S. aureus are very likely to possess co-resistance to fluoroquinolones, including levofloxacin. Therefore levofloxacin is not recommended for the treatment of known or suspected MRSA infections unless laboratory results have confirmed susceptibility of the organism to levofloxacin (and commonly recommended antibacterial agents for the treatment of MRSA-infections are considered inappropriate).

Levofloxacin may be used in the treatment of Acute Bacterial Sinusitis and Acute Exacerbation of Chronic Bronchitis when these infections have been adequately diagnosed.

Resistance to fluoroquinolones of E. coli – the most common pathogen involved in urinary tract infections – varies across the European Union. Prescribers are advised to take into account the local prevalence of resistance in E. coli to fluoroquinolones.

Inhalation Anthrax: Use in humans is based on in vitro Bacillus anthracis susceptibility data and on animal experimental data together with limited human data. Treating physicians should refer to national and/or international consensus documents regarding the treatment of anthrax.

 

Tendinitis and tendon rupture

Tendinitis and tendon rupture (especially but not limited to Achilles tendon), sometimes bilateral, may occur as early as within 48 hours of starting treatment with quinolones and fluoroquinolones and have been reported to occur even up to several months after discontinuation of treatment.

The risk of tendinitis and tendon rupture is increased in patients receiving daily doses of 1,000 mg levofloxacin, in older patients, patients with renal impairment, patients with solid organ transplants, and those treated concurrently with corticosteroids. Therefore, concomitant use of corticosteroids should be avoided.

At the first sign of tendinitis (e.g. painful swelling, inflammation) the treatment with levofloxacin should be discontinued and alternative treatment should be considered. The affected limb(s) should be appropriately treated (e.g. immobilisation). Corticosteroids should not be used if signs of tendinopathy occur.

 

Clostridium difficile-associated disease

Diarrhoea, particularly if severe, persistent and/or bloody, during or after treatment with levofloxacin (including several weeks after treatment), may be symptomatic of Clostridium difficile-associated disease (CDAD).

CDAD may range in severity from mild to life threatening, the most severe form of which is pseudomembranous colitis (see section 4.8). It is therefore important to consider this diagnosis in patients who develop serious diarrhoea during or after treatment with levofloxacin. If CDAD is suspected or confirmed, [Levofloxacin Sandoz, film-coated tablets] should be stopped immediately and appropriate treatment initiated without delay. Anti-peristaltic medicinal products are contraindicated in this clinical situation.

 

Patients predisposed to seizures

Quinolones may lower the seizure threshold and may trigger seizures. Levofloxacin is contraindicated in patients with a history of epilepsy (see section 4.3) and, as with other quinolones, should be used with extreme caution in patients predisposed to seizures or concomitant treatment with active substances that lower the cerebral seizure threshold, such as theophylline (see section 4.5). In case of convulsive seizures (see section 4.8), treatment with Levofloxacin should be discontinued.

 

Patients with G-6- phosphate dehydrogenase deficiency

Patients with latent or actual defects in glucose-6-phosphate dehydrogenase activity may be prone to haemolytic reactions when treated with quinolone antibacterial agents. Therefore, if levofloxacin has to be used in these patients, potential occurrence of haemolysis should be monitored.

 

Patients with renal impairment

Since levofloxacin is excreted mainly by the kidneys, the dose of levofloxacin should be adjusted in patients with renal impairment (see section 4.2).

 

Hypersensitivity reactions

Levofloxacin can cause serious, potentially fatal hypersensitivity reactions (e.g. angioedema up to anaphylactic shock), occasionally following the initial dose (see section 4.8). Patients should discontinue treatment immediately and contact their physician or an emergency physician, who will initiate appropriate emergency measures.

 

Severe cutaneous adverse reactions

Severe cutaneous adverse reactions (SCARs) including toxic epidermal necrolysis (TEN: also known as Lyell's syndrome), Stevens Johnson syndrome (SJS) and drug reaction with eosinophilia and systemic symptoms (DRESS), which could be life-threatening or fatal, have been reported with levofloxacin (see section 4.8). At the time of prescription, patients should be advised of the signs and symptoms of severe skin reactions, and be closely monitored. If signs and symptoms suggestive of these reactions appear, levofloxacin should be discontinued immediately and an alternative treatment should be considered. If the patient has developed a serious reaction such as SJS, TEN or DRESS with the use of levofloxacin, treatment with levofloxacin must not be restarted in this patient at any time.

 

Dysglycaemia

As with all quinolones, disturbances in blood glucose, including both hypoglycaemia and hyperglycaemia have been reported (see section 4.8), usually in diabetic patients receiving concomitant treatment with an oral hypoglycaemic agent (e.g., glibenclamide) or with insulin. Cases of hypoglycaemic coma have been reported. In diabetic patients, careful monitoring of blood glucose is recommended.(see section 4.8).

 

Prevention of photosensitisation

Photosensitisation has been reported with levofloxacin (see section 4.8). It is recommended that patients should not expose themselves unnecessarily to strong sunlight or to artificial UV rays (e.g. sunray lamp, solarium), during treatment and for 48 hours following treatment discontinuation in order to prevent photosensitisation.

 

Patients treated with Vitamin K antagonists

Due to possible increase in coagulation tests (PT/INR) and/or bleeding in patients treated with levofloxacin in combination with a vitamin K antagonist (e.g. warfarin), coagulation tests should be monitored when these drugs are given concomitantly (see section 4.5).

 

Psychotic reactions

Psychotic reactions have been reported in patients receiving quinolones, including levofloxacin. In very rare cases these have progressed to suicidal thoughts and self-endangering behaviour- sometimes after only a single dose of levofloxacin (see section 4.8). In the event that the patient develops these reactions, levofloxacin should be discontinued and appropriate measures instituted. Caution is recommended if levofloxacin is to be used in psychotic patients or in patients with history of psychiatric disease.

 

QT interval prolongation

Caution should be taken when using fluoroquinolones, including levofloxacin, in patients with known risk factors for prolongation of the QT interval such as, for example:

- congenital long QT syndrome

- concomitant use of drugs that are known to prolong the QT interval (e.g. Class IA and III antiarrhythmics, tricyclic antidepressants, macrolides, antipsychotics)
- uncorrected electrolyte imbalance (e.g. hypokalemia, hypomagnesemia)
- cardiac disease (e.g. heart failure, myocardial infarction, bradycardia)
Elderly and women may be more sensitive to QTc-prolonging medications. Therefore, caution should be taken when using fluoroquinolones, including levofloxacin, in these populations.
(see sections 4.2 Elderly, 4.5, 4.8 and 4.9).

 

Aortic aneurysm and dissection

Epidemiologic studies report an increased risk of aortic aneurysm and dissection, particularly in elderly patients, and of aortic and mitral valve regurgitation after intake of fluoroquinolones. Cases of aortic aneurysm and dissection, sometimes complicated by rupture (including fatal ones), and of regurgitation/incompetence of any of the heart valves have been reported in patients receiving fluoroquinolones (see section 4.8).
Therefore, fluoroquinolones should only be used after careful benefit-risk assessment and after consideration of other therapeutic options in patients with positive family history of aneurysm disease or congenital heart valve disease, or in patients diagnosed with pre-existing aortic aneurysm and/or aortic dissection or heart valve disease, or in presence of other risk factors or conditions predisposing
− for both aortic aneurysm and dissection and heart valve regurgitation/incompetence (e.g. connective tissue disorders such as Marfan syndrome or Ehlers-Danlos syndrome, Turner syndrome, Behcet’s disease, hypertension, rheumatoid arthritis) or additionally
− for aortic aneurysm and dissection (e.g. vascular disorders such as Takayasu arteritis or giant cell arteritis, or known atherosclerosis, or Sjögren’s syndrome) or additionally
− for heart valve regurgitation/incompetence (e.g. infective endocarditis).
The risk of aortic aneurysm and dissection, and their rupture may also be increased in patients treated concurrently with systemic corticosteroids.
In case of sudden abdominal, chest or back pain, patients should be advised to immediately consult a physician in an emergency department.
Patients should be advised to seek immediate medical attention in case of acute dyspnoea, new onset of heart palpitations, or development of oedema of the abdomen or lower extremities.

 

Peripheral neuropathy

Cases of sensory or sensorimotor polyneuropathy resulting in paraesthesia, hypaesthesia, dysaesthesia, or weakness have been reported in patients receiving quinolones and fluoroquinolones. Patients under treatment with levofloxacin should be advised to inform their doctor prior to continuing treatment if symptoms of neuropathy such as pain, burning, tingling, numbness, or weakness develop in order to prevent the development of potentially irreversible condition (see section 4.8).

 

Hepatobiliary disorders

Cases of hepatic necrosis up to fatal hepatic failure have been reported with levofloxacin, primarily in patients with severe underlying diseases, e.g. sepsis (see section 4.8). Patients should be advised to stop treatment and contact their doctor if signs and symptoms of hepatic disease develop such as anorexia, jaundice, dark urine, pruritus or tender abdomen.

 

Exacerbation of myasthenia gravis

Fluoroquinolones, including levofloxacin, have neuromuscular blocking activity and may exacerbate muscle weakness in patients with myasthenia gravis. Postmarketing serious adverse reactions, including deaths and the requirement for respiratory support, have been associated with fluoroquinolone use in patients with myasthenia gravis. Levofloxacin is not recommended in patients with a known history of myasthenia gravis.

 

Vision disorders

If vision becomes impaired or any effects on the eyes are experienced, an eye specialist should be consulted immediately (see sections 4.7 and 4.8).

 

Superinfection

The use of levofloxacin, especially if prolonged, may result in overgrowth of non-susceptible organisms. If superinfection occurs during therapy, appropriate measures should be taken.

 

Interference with laboratory tests
In patients treated with levofloxacin, determination of opiates in urine may give false-positive results. It may be necessary to confirm positive opiate screens by more specific method.
Levofloxacin may inhibit the growth of Mycobacterium tuberculosis and, therefore, may give false-negative results in the bacteriological diagnosis of tuberculosis.

Lactose
This product contains lactose. Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicine.

Sodium
This medicine contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially ‘sodium-free’.

Effect of other medicinal products on [Levofloxacin Sandoz, film-coated tablets]
Iron salts, zinc salts, magnesium- or aluminium-containing antacids, didanosine
Levofloxacin absorption is significantly reduced when iron salts, or magnesium- or aluminium-containing antacids, or didanosine (only didanosine formulations with aluminium or magnesium containing buffering agents) are administered concomitantly with levofloxacin tablets. Concurrent administration of fluoroquinolones with multi-vitamins containing zinc appears to reduce their oral absorption. It is recommended that preparations containing divalent or trivalent cations such as iron salts, zinc salts or magnesium- or aluminium-containing antacids, or didanosine (only didanosine formulations with aluminium or magnesium containing buffering agents) should not be taken 2 hours before or after Levofloxacin tablet administration (see section 4.2). Calcium salts have a minimal effect on the oral absorption of levofloxacin

Sucralfate
The bioavailability of levofloxacin tablets is significantly reduced when administered together with sucralfate. If the patient is to receive both sucralfate and levofloxacin, it is best to administer sucralfate 2 hours after the levofloxacin tablet administration (see section 4.2).

Theophylline, fenbufen or similar non-steroidal anti-inflammatory drugs
No pharmacokinetic interactions of levofloxacin were found with theophylline in a clinical study. However a pronounced lowering of the cerebral seizure threshold may occur when quinolones are given concurrently with theophylline, non-steroidal anti-inflammatory drugs, or other agents which lower the seizure threshold.
Levofloxacin concentrations were about 13% higher in the presence of fenbufen than when administered alone.

Probenecid and cimetidine
Probenecid and cimetidine had a statistically significant effect on the elimination of levofloxacin. The renal clearance of levofloxacin was reduced by cimetidine (24%) and probenecid (34%). This is because both drugs are capable of blocking the renal tubular secretion of levofloxacin. However, at the tested doses in the study, the statistically significant kinetic differences are unlikely to be of clinical relevance.
Caution should be exercised when levofloxacin is coadministered with drugs that affect the tubular renal secretion such as probenecid and cimetidine, especially in renally impaired patients.

Other relevant information

Clinical pharmacology studies have shown that the pharmacokinetics of levofloxacin were not affected to any clinically relevant extent when levofloxacin was administered together with the following drugs: calcium carbonate, digoxin, glibenclamide, ranitidine.

Effect of [Levofloxacin Sandoz, film-coated tablets] on other medicinal products

Ciclosporin
The half-life of ciclosporin was increased by 33% when coadministered with levofloxacin.

Vitamin K antagonists
Increased coagulation tests (PT/INR) and/or bleeding, which may be severe, have been reported in patients treated with levofloxacin in combination with a vitamin K antagonist (e.g. warfarin). Coagulation tests, therefore, should be monitored in patients treated with vitamin K antagonists (see section 4.4).

Drugs known to prolong QT interval
Levofloxacin, like other fluoroquinolones, should be used with caution in patients receiving drugs known to prolong the QT interval (e.g. Class IA and III antiarrhythmics, tricyclic antidepressants, macrolides, antipsychotics) (See section 4.4 QT interval prolongation).

Other relevant information
In a pharmacokinetic interaction study, levofloxacin did not affect the pharmacokinetics of theophylline (which is a probe substrate for CYP1A2), indicating that levofloxacin is not a CYP1A2 inhibitor.
Other forms of interactions

Food
There is no clinically relevant interaction with food. Levofloxacin tablets may therefore be administered regardless of food intake.

Pregnancy

There are limited amount of data from the use of levofloxacin in pregnant women. Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity (see section 5.3). However in the absence of human data and due to that experimental data suggest a risk of damage by fluoroquinolones to the weight-bearing cartilage of the growing organism, levofloxacin must not be used in pregnant women (see sections 4.3 and 5.3).

 

Breast-feeding

Levofloxacin is contraindicated in breast-feeding women. There is insufficient information on the excretion of levofloxacin in human milk; however other fluoroquinolones are excreted in breast milk. In the absence of human data and due to that experimental data suggest a risk of damage by fluoroquinolones to the weight-bearing cartilage of the growing organism, levofloxacin must not be used in breast-feeding women (see sections 4.3 and 5.3).

 

Fertility

Levofloxacin caused no impairment of fertility or reproductive performance in rats.

Some undesirable effects (e.g. dizziness/vertigo, drowsiness, visual disturbances) may impair the patient’s ability to concentrate and react, and therefore may constitute a risk in situations where these abilities are of special importance (e.g. driving a car or operating machinery).

The information given below is based on data from clinical studies in more than 8300 patients and on extensive post marketing experience.

 

Frequencies are defined using the following convention: very common (≥1/10), common (≥1/100,

<1/10), uncommon (≥1/1000, <1/100), rare (≥1/10000, <1/1000), very rare (<1/10000), not known (cannot be estimated from the available data).

 

Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.

 

System organ class	Common (³1/100 to <1/10 )	Uncommon (³1/1,000 to <1/100)	Rare (³1/10,000 to <1/1,000)	Not known (cannot be estimated from available data)
Infections and		Fungal
infestations		infection
		including
		Candida
		infection
		Pathogen
		resistance
Blood and		Leukopenia	Thrombocytopeni	Pancytopenia
Lymphatic		Eosinophilia	a	Agranulocytosis
system disorders			Neutropenia	Haemolytic
				anaemia
Immune system disorders			Angioedema Hypersensitivity	Anaphylactic shocka
			(see section 4.4)	Anaphylactoid shocka  (see section
				4.4)
Endocrine			Syndrome of
disorders			inappropriate
			secretion of
			antidiuretic
			hormone (SIADH)
Metabolism and		Anorexia	Hypoglycaemia	Hyperglycaemia
nutrition			particularly in	Hypoglycaemic
disorders			diabetic patients	coma (see section
			(see section 4.4)	4.4)
Psychiatric	Insomnia	Anxiety	Psychotic	Psychotic disorders
disorders*		Confusional	reactions (with	with self-
		state	e.g. hallucination,	endangering
		Nervousness	paranoia)	behaviour
			Depression	including suicidal
			Agitation	ideation or suicide
			Abnormal dreams	attempt (see section
			Nightmares	4.4)

 

System organ class	Common (³1/100 to <1/10 )	Uncommon (³1/1,000 to <1/100)	Rare (³1/10,000 to <1/1,000)	Not known (cannot be estimated from available data)
Nervous system disorders*	Headache Dizziness	Somnolence Tremor Dysgeusia	Convulsion (see sections 4.3 and 4.4) Paraesthesia	Peripheral sensory neuropathy (see section 4.4) Peripheral sensory motor neuropathy (see section 4.4) Parosmia including anosmia Dyskinesia Extrapyramidal disorder Ageusia Syncope Benign intracranial hypertension
Eye disorders*			Visual disturbances such as blurred vision (see section 4.4)	Transient vision loss (see section 4.4)
Ear and Labyrinth disorders*		Vertigo	Tinnitus	Hearing loss Hearing impaired
Cardiac disorders			Tachycardia Palpitation	Ventricular tachycardia, which may result in cardiac arrest Ventricular arrhythmia and torsade de pointes (reported predominantly in patients with risk factors of QT prolongation), electrocardiogram QT prolonged (see sections 4.4 and 4.9)
Vascular disorders			Hypotension
Respiratory, thoracic and mediastinal		Dyspnoea		Bronchospasm Pneumonitis allergic

 

System organ class	Common (³1/100 to <1/10 )	Uncommon (³1/1,000 to <1/100)	Rare (³1/10,000 to <1/1,000)	Not known (cannot be estimated from available data)
disorders
Gastro-intestinal	Diarrhoea	Abdominal pain		Diarrhoea –
disorders	Vomiting	Dyspepsia		haemorrhagic
	Nausea	Flatulence		which in very rare
		Constipation		cases may be
				indicative of
				enterocolitis,
				including
				pseudomembranou
				s colitis (see
				section 4.4)
				Pancreatitis
Hepatobiliary	Hepatic enzyme	Blood bilirubin		Jaundice and
disorders	increased	increased		severe liver injury,
	(ALT/AST,			including cases
	alkaline			with fatal acute
	phosphatase,			liver failure,
	GGT)			primarily in
				patients with severe
				underlying diseases
				(see section 4.4)
				Hepatitis
Skin and		Rash	Drug Reaction	Toxic epidermal
subcutaneous		Pruritus	with Eosinophilia	necrolysis
tissue disorders b		Urticaria	and Systemic	Stevens-Johnson
		Hyperhidrosis	Symptoms	syndrome
			(DRESS) (see	Erythema
			section 4.4), Fixed	multiforme
			drug eruption	Photosensitivity
				reaction (see
				section 4.4)
				Leukocytoclastic
				vasculitis
				Stomatitis

 

 

System organ class Common (³1/100 to <1/10 ) Uncommon (³1/1,000 to <1/100) Rare (³1/10,000 to <1/1,000) Not known (cannot be estimated from available data) Musculoskeletal   Arthralgia Tendon disorders Rhabdomyolysis and connective Myalgia (see sections 4.3 Tendon rupture tissue disorders*   and 4.4) including (e.g. Achilles     tendinitis (e.g. tendon) (see     Achilles tendon) section 4.3 and 4.4)     Muscular Ligament rupture     weakness which Muscle rupture     may be of special Arthritis     importance in       patients with       myasthenia gravis       (see section 4.4)   Renal and   Blood Renal failure acute   Urinary creatinine (e.g. due to disorders increased interstitial     nephritis) General   Asthenia Pyrexia Pain (including disorders and pain in back, chest, administration and extremities) site conditions*

a Anaphylactic and anaphylactoid reactions may sometimes occur even after the first dose

 

b Mucocutaneous reactions may sometimes occur even after the first dose

*Very rare cases of prolonged (up to months or years), disabling and potentially irreversible serious drug reactions affecting several, sometimes multiple, system organ classes and senses (including reactions such as tendonitis, tendon rupture, arthralgia, pain in extremities, gait disturbance, neuropathies associated with paraesthesia, depression, fatigue, memory impairment, sleep disorders, and impairment of hearing, vision, taste and smell) have been reported in association with the use of quinolones and fluoroquinolones in some cases irrespective of pre-existing risk factors (see section 4.4).

 

Other undesirable effects which have been associated with fluoroquinolone administration include: attacks of porphyria in patients with porphyria.

• To report any side effect(s):

 

• Saudi Arabia:

NPC contact information Saudi Arabia:              The National Pharmacovigilance Centre (NPC):              SFDA Call Center: 19999              E-mail: npc.drug@sfda.gov.sa              Website ade.sfda.gov.sa

 

• Other GCC states:

-   Please contact the relevant competent authority.

 

According to toxicity studies in animals or clinical pharmacology studies performed with supra- therapeutic doses, the most important signs to be expected following acute overdose of Levofloxacin Sandoz are central nervous system symptoms such as confusion, dizziness, impairment of consciousness,

 

and convulsive seizures, increases in QT interval as well as gastro-intestinal reactions such as nausea and mucosal erosions.

 

CNS effects including confusional state, convulsion, hallucination, and tremor have been observed in post marketing experience.

 

In the event of overdose, symptomatic treatment should be implemented. ECG monitoring should be undertaken, because of the possibility of QT interval prolongation. Antacids may be used for protection of gastric mucosa. Haemodialysis, including peritoneal dialysis and CAPD, are not effective in removing levofloxacin from the body. No specific antidote exists.

Pharmacotherapeutic group: quinolone antibacterials, fluoroquinolones ATC code: J01MA12

Levofloxacin is a synthetic antibacterial agent of the fluoroquinolone class and is the S (-) enantiomer of the racemic active substance ofloxacin.

 

Mechanism of action

As a fluoroquinolone antibacterial agent, levofloxacin acts on the DNA-DNA-gyrase complex and topoisomerase IV.

 

Pharmacokinetic/pharmacodynamic relationship

The degree of the bactericidal activity of levofloxacin depends on the ratio of the maximum concentration in serum (Cmax) or the area under the curve (AUC) and the minimal inhibitory concentration (MIC).

 

Mechanism of resistance

Resistance to levofloxacin is acquired through a stepwise process by target site mutations in both type II topoisomerases, DNA gyrase and topoisomerase IV. Other resistance mechanisms such as permeation barriers (common in Pseudomonas aeruginosa) and efflux mechanisms may also affect susceptibility to levofloxacin.

 

Cross-resistance between levofloxacin and other fluoroquinolones is observed. Due to the mechanism of action, there is generally no cross-resistance between levofloxacin and other classes of antibacterial agents.

 

Breakpoints

The EUCAST recommended MIC breakpoints for levofloxacin, separating susceptible from intermediately susceptible organisms and intermediately susceptible from resistant organisms are presented in the below table for MIC testing (mg/L).

 

EUCAST clinical MIC breakpoints for levofloxacin (version 2.0, 2012-01-01):

 

	Susceptible	Resistant
Enterobacteriacae	≤1 mg/L	>2 mg/L
Pseudomonas spp. Acinetobacter spp.
Staphylococcus spp.
S.pneumoniae 1	≤2 mg/L	>2 mg/L
Streptococcus A, B, C, G	≤1 mg/L	>2 mg/L
H.influenzae 2, 3	≤1 mg/L	>1 mg/L
M.catarrhalis 3	≤1 mg/L	>1 mg/L
Non-species related breakpoints 4	≤1 mg/L	>2 mg/L

 

1.  The breakpoints for levofloxacin relate to high dose therapy. 2.  Low-level fluoroquinolone resistance (ciprofloxacin MICs of 0.12-0.5 mg/L) may occur but there is no evidence that this resistance is of clinical importance in respiratory tract infections with H. influenzae. 3.  Strains with MIC values above the susceptible breakpoint are very rare or not yet reported. The identification and antimicrobial susceptibility tests on any such isolate must be repeated and if the result is confirmed the isolate must be sent to a reference laboratory. Until there is evidence regarding clinical response for confirmed isolates with MIC above the current resistant breakpoint they should be reported resistant. 4.  Breakpoints apply to an oral dose of 500 mg x 1 to 500 mg x 2 and an intravenous dose of 500 mg x 1 to 500 mg x 2.

 

 

The prevalence of resistance may vary geographically and with time for selected species and local information on resistance is desirable, particularly when treating severe infections. As necessary, expert advice should be sought when the local prevalence of resistance is such that the utility of the agent in at least some types of infections is questionable.

Commonly susceptible species

Aerobic Gram-positive bacteria Bacillus anthracis Staphylococcus aureus methicillin-susceptible Staphylococcus saprophyticus Streptococci, group C and G Streptococcus agalactiae Streptococcus pneumoniae Streptococcus pyogenes Aerobic Gram-negative bacteria Eikenella corrodens Haemophilus influenzae Haemophilus para-influenzae Klebsiella oxytoca Moraxella catarrhalis Pasteurella multocida Proteus vulgaris Providencia rettgeri Anaerobic bacteria

Peptostreptococcus Other Chlamydophila pneumoniae Chlamydophila psittaci Chlamydia trachomatis Legionella pneumophila Mycoplasma pneumoniae Mycoplasma hominis Ureaplasma urealyticum   Species for which acquired resistance may be a problem Aerobic Gram-positive bacteria Enterococcus faecalis Staphylococcus aureus methicillin-resistant# Coagulase negative Staphylococcus spp. Aerobic Gram-negative bacteria Acinetobacter baumannii Citrobacter freundii Enterobacter aerogenes Enterobacter cloacae Escherichia coli Klebsiella pneumoniae Morganella morganii Proteus mirabilis Providencia stuartii Pseudomonas aeruginosa Serratia marcescens Anaerobic bacteria Bacteroides fragilis Inherently resistant strains Aerobic Gram-positive bacteria Enterococcus faecium

# Methicillin-resistant S. aureus are very likely to possess co-resistance to fluoroquinolones, including levofloxacin.

1.1        Absorption

Orally administered levofloxacin is rapidly and almost completely absorbed with peak plasma concentrations being obtained within 1 – 2 h. The absolute bioavailability is 99 - 100 %.

Food has little effect on the absorption of levofloxacin.

Steady state conditions are reached within 48 hours following a 500 mg once or twice daily dosage regimen.

 

Distribution

Approximately 30 - 40 % of levofloxacin is bound to serum protein.

The mean volume of distribution of levofloxacin is approximately 100 l after single and repeated 500 mg doses, indicating widespread distribution into body tissues.

 

Penetration into tissues and body fluids

Levofloxacin has been shown to penetrate into bronchial mucosa, epithelial lining fluid, alveolar macrophages, lung tissue, skin (blister fluid), prostatic tissue and urine. However, levofloxacin has poor penetration intro cerebro-spinal fluid.

 

Biotransformation

Levofloxacin is metabolised to a very small extent, the metabolites being desmethyl-levofloxacin and levofloxacin N-oxide. These metabolites account for < 5 % of the dose and are excreted in urine.

Levofloxacin is stereochemically stable and does not undergo chiral inversion.

 

Elimination

Following oral and intravenous administration of levofloxacin, it is eliminated relatively slowly from the plasma (t½: 6 - 8 h). Excretion is primarily by the renal route (> 85 % of the administered dose). The mean apparent total body clearance of levofloxacin following a 500 mg single dose was 175 ±

29.2 mL/min.

There are no major differences in the pharmacokinetics of levofloxacin following intravenous and oral administration, suggesting that the oral and intravenous routes are interchangeable.

 

Linearity

Levofloxacin obeys linear pharmacokinetics over a range of 50 to 1000 mg.

 

Special populations

Subjects with renal insufficiency

The pharmacokinetics of levofloxacin are affected by renal impairment. With decreasing renal function renal elimination and clearance are decreased, and elimination half-lives increased as shown in the table below:

 

Pharmacokinetics in renal insufficiency following single oral 500 mg dose

 

ClcrmL/min	< 20	20 - 49	50 - 80
ClRmL/min	13	26	57
t1/2h	35	27	9

 

Elderly

There are no significant differences in levofloxacin pharmacokinetics between young and elderly subjects, except those associated with differences in creatinine clearance.

 

Gender differences

Separate analysis for male and female subjects showed small to marginal gender differences in levofloxacin pharmacokinetics. There is no evidence that these gender differences are of clinical relevance.

Non-clinical data reveal no special hazard for humans based on conventional studies of single dose toxicity, repeated dose toxicity, carcinogenic potential and toxicity to reproduction and development.

 

Levofloxacin caused no impairment of fertility or reproductive performance in rats and its only effect on fetuses was delayed maturation as a result of maternal toxicity.

 

Levofloxacin did not induce gene mutations in bacterial or mammalian cells but did induce chromosome aberrations in Chinese hamster lung cells in vitro. These effects can be attributed to inhibition of topoisomerase II. In vivo tests (micronucleus, sister chromatid exchange, unscheduled DNA synthesis, dominant lethal tests) did not show any genotoxic potential.

Studies in the mouse showed levofloxacin to have phototoxic activity only at very high doses. Levofloxacin did not show any genotoxic potential in a photomutagenicity assay, and it reduced tumour development in a photocarcinogenity study.

 

In common with other fluoroquinolones, levofloxacin showed effects on cartilage (blistering and cavities) in rats and dogs. These findings were more marked in young animals.

Tablet core:

• Lactose monohydrate
• Povidone K30
• Sodium starch glycolate (type A)
• Talc
• Silica, colloidal anhydrous
• Croscarmellose sodium
• Glycerol dibehenate

Tablet coating:

• Hypromellose
• Hydroxypropylcellulose
• Macrogol 6000
• Titanium dioxide (E 171)
• Iron oxide, yellow (E 172)
• Iron oxide, red (E 172)
• Talc

Not applicable.

3 years

This medicinal product does not require any special storage conditions

The film-coated tablets are packed in aluminium/PVC/TE/PVDC blister and inserted in a carton box.
Blister: 1, 3, 4, 5, 7, 8, 10, 14, 20, 28, 30, 50, 60, 90, 100, 200 and 500 film-coated tablets.
Not all pack sizes may be marketed.

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.