zaldiar tablets are indicated for the symptomatic treatment of moderate to severe pain.

 

The use of <Trademark> should be restricted to patients whose moderate to severe pain is considered to require a combination of tramadol and paracetamol (see also Section 5.1).

 

Posology

 

The use of zaldiar should be restricted to patients whose moderate to severe pain is considered to require a combination of tramadol and paracetamol.

 

The dose should be adjusted to intensity of pain and the sensitivity of the individual patient. The lowest effective dose for analgesia should generally be selected. The total dose of 8 tablets (equivalent to 300 mg tramadol hydrochloride and 2600 mg paracetamol) per day should not be exceeded. The dosing interval should not be less than six hours.

 

Adults and adolescents (12 years and older)

An initial dose of two tablets of zaldiar is recommended Additional doses can be taken as needed, not exceeding 8 tablets (equivalent to 300 mg tramadol and 2600 mg paracetamol) per day.

The dosing interval should not be less than six hours.

 

zaldiar should under no circumstances be administered for longer than is strictly necessary (see also section 4.4 - Special warnings and precautions for use). If repeated use or

 

long term treatment with zaldiar is required as a result of the nature and severity of the illness, then careful, regular monitoring should take place (with breaks in the treatment, where possible), to assess whether continuation of the treatment is necessary.

 

Paediatric population

 

The effective and safe use of zaldiar has not been established in children below the age of 12 years. Treatment is therefore not recommended in this population.

 

Older people

 

A dose adjustment is not usually necessary in patients up to 75 years without clinically manifest hepatic or renal insufficiency. In elderly patients over 75 years elimination may be prolonged. Therefore, if necessary the dosage interval is to be extended according to the patient's requirements.

 

Renal insufficiency/dialysis

 

In patients with renal insufficiency the elimination of tramadol is delayed. In these patients prolongation of the dosage intervals should be carefully considered according to the patient's requirements.

 

Hepatic impairment

 

In patients with hepatic impairment the elimination of tramadol is delayed. In these patients prolongation of the dosage intervals should be carefully considered according to the patient’s requirements (see section 4.4). Because of the presence of paracetamol <Tradename> should not be used in patients with severe hepatic impairment (see Section 4.3).

 

Method of administration

 

Oral use

 

Tablets must be swallowed whole, with a sufficient quantity of liquid. They must not be broken or chewed.

 

- Hypersensitivity to the active substances or to any of the excipients listed in section 6.1 - acute intoxication with alcohol, hypnotic drugs, centrally-acting analgesics, opioids or psychotropic drugs, - zaldiar should not be administered to patients who are receiving monoamine oxidase inhibitors or within two weeks of their withdrawal (see 4.5. Interactions with other medicinal products and other forms of interaction), - severe hepatic impairment, - epilepsy not controlled by treatment (see. 4.4. Special Warnings).

Warnings:

 

-           In adults and adolescents 12 years and older. The maximum dose of 8 tablets of

zaldiar should not be exceeded. In order to avoid inadvertent overdose, patients should be advised not to exceed the recommended dose and not to use any other paracetamol (including over the counter) or tramadol hydrochloride containing products concurrently without the advice of a physician.

-           In severe renal insufficiency (creatinine clearance <10 ml/mm), zaldiar is not recommended.

-           In patients with severe hepatic impairment zaldiar should not be used (See Section 4.3). The hazards of paracetamol overdose are greater in patients with non-cirrhotic alcoholic liver disease. In moderate cases prolongation of dosage interval should be carefully considered.

-          In severe respiratory insufficiency, zaldiar is not recommended.

-          Tramadol is not suitable as a substitute in opioid-dependent patients. Although it is an opioid agonist, tramadol cannot suppress morphine withdrawal symptoms.

-           Convulsions have been reported in tramadol-treated patients susceptible to seizures or taking other medications that lower the seizure threshold, especially selective serotonin re- uptake inhibitors, tricyclic antidepressants, antipsychotics, centrally acting analgesics or local anaesthesia. Epileptic patients controlled by a treatment or patients susceptible to seizures should be treated with zaldiar only if there are compelling circumstances. Convulsions have been reported in patients receiving tramadol at the recommended dose levels. The risk may be increased when doses of tramadol exceed the recommended upper dose limit

-           Concomitant use of opioid agonists-antagonists (nalbuphine, buprenorphine, pentazocine) is not recommended (see section 4.5).

 

Precautions for use

 

Tolerance and physical and/or psychological dependence may develop, even at therapeutic doses. The clinical need for analgesic treatment should be reviewed regularly (see 4.2). In opioid-dependent patients and patients with a history of drug abuse or dependence, treatment should only be for short period and under medical supervision. zaldiar should be used with caution in patients with cranial trauma, in patients prone to convulsive disorder, biliary tract disorders, in a state of shock, in an altered state of consciousness for unknown reasons, with problems affecting the respiratory center or the respiratory function, or with an increased intracranial pressure.

 

Paracetamol in overdose may cause hepatic toxicity in some patients.

 

Symptoms of withdrawal reaction, similar to those occurring during opiate withdrawal, may occur even at therapeutic doses and for short term treatment (see section 4.8). Withdrawal symptoms may be avoided by taper it at the time of discontinuation especially after long treatment periods. Rarely, cases of dependence and abuse have been reported (see section 4.8).

 

 

In one study, use of tramadol during general anaesthesia with enflurane and nitrous oxide was reported to enhance intra-operative recall. Until further information is available, use of tramadol during light planes of anaesthesia should be avoided.

 

zaldiar tablets contain lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicinal product.

Concomitant use is contraindicated with:

 

·        Non-selective MAO Inhibitors

Risk of serotonergic syndrome: diarrhoea, tachycardia, hyperhidrosis, trembling, confusional state, even coma.

 

·       Selective-A MAO Inhibitors

Extrapolation from non-selective MAO inhibitors

Risk of serotonergic syndrome: diarrhoea, tachycardia, hyperhidrosis, trembling, confusional state, even coma.

 

·       Selective-B MAO Inhibitors

Central excitation symptoms evocative of a serotonergic syndrome: diarrhoea, tachycardia, hyperhidrosis, trembling, confusional state, even coma.

 

In case of recent treatment with MAO inhibitors, a delay of two weeks should occur before treatment with tramadol

 

Concomitant use is not recommended with:

 

·     Alcohol

Alcohol increases the sedative effect of opioid analgesics.

The effect on alertness can make driving of vehicles and the use of machines dangerous. Avoid intake of alcoholic drinks and of medicinal products containing alcohol.

 

·     Carbamazepine and other enzyme inducers

Risk of reduced efficacy and shorter duration due to decreased plasma concentrations of tramadol.

 

·     Opioid agonists-antagonists (buprenorphine, nalbuphine, pentazocine)

Decrease of the analgesic effect by competitive blocking effect at the receptors, with the risk of occurrence of withdrawal syndrome.

 

Concomitant use which needs to be taken into consideration:

 

·       Tramadol can induce convulsions and increase the potential for selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants, antipsychotics and seizure threshold-lowering medicinal products (such as bupropion, mirtazapine, tetrahydrocannabinol) to cause convulsions.

 

·     Concomitant therapeutic use of tramadol and serotonergic drugs such as selective serotonin re-uptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), MAO inhibitors (see section 4.3), tricyclic antidepressants and mirtazapine may cause serotonin toxicity. Serotonin syndrome is likely when one of the following is observed:

·       Spontaneous clonus

·       Inducible or ocular clonus with agitation or diaphoresis ,

·       Tremor and hyperreflexia

 

·        Hypertonia and body temperature > 38 °C and inducible or ocular clonus.

Withdrawal of the serotonergic drugs usually brings about a rapid improvement. Treatment depends on the type and severity of the symptoms.

 

·       Other opioid derivatives (including antitussive drugs and substitutive treatments), benzodiazepines and barbiturates

Increased risk of respiratory depression which can be fatal in cases of overdose.

 

·      Other central nervous system depressants, such as other opioid derivatives (including antitussive drugs and substitutive treatments), barbiturates, benzodiazepines, other anxiolytics, hypnotics, sedative antidepressants, sedative antihistamines, neuroleptics, centrally-acting antihypertensive drugs, thalidomide and baclofen.

These drugs can cause increased central depression. The effect on alertness can make driving of vehicles and the use of machines dangerous.

 

·     As medically appropriate, periodic evaluation of prothrombin time should be performed when zaldiar and warfarin like compounds are administered concurrently due to reports of increased INR.

 

·       In a limited number of studies the pre- or postoperative application of the antiemetic 5- HT3 antagonist ondansetron increased the requirement of tramadol in patients with postoperative pain.

 

Pregnancy

 

Since zaldiar is a fixed combination of active ingredients including tramadol, it should not be used during pregnancy.

 

·      Data regarding paracetamol:

 

Epidemiological studies in human pregnancy have shown no ill effects due to paracetamol used in the recommended dosages.

 

·      Data regarding tramadol:

Tramadol should not be used during pregnancy as there is inadequate evidence available to assess the safety of tramadol in pregnant women. Tramadol administered before or during birth does not affect uterine contractility. In neonates it may induce changes in the respiratory rate which are usually not clinically relevant. Long-term treatment during pregnancy may lead to withdrawal symptoms in the newborn after birth, as a consequence of habituation.

 

Breast-feeding:

 

Since zaldiar is a fixed combination of active ingredients including tramadol, it should not be ingested during breast feeding.

 

·      Data regarding paracetamol:

Paracetamol is excreted in breast milk  but  not  in  a  clinically  significant  amount. Available published data do not contraindicate breast feeding by women using single ingredient medicinal products containing only paracetamol.

 

 

·      Data regarding tramadol:

Approximately 0.1% of the maternal dose of tramadol is excreted in breast milk. In the immediate post-partum period, for maternal oral daily dosage up to 400 mg, this corresponds to a mean amount of tramadol ingested by breast-fed infants of 3% of the maternal weight- adjusted dosage. For this reason tramadol should not be used during lactation or alternatively, breast-feeding should be discontinued during treatment with tramadol. Discontinuation of breast-feeding is generally not necessary following a single dose of tramadol.

 

Fertility

 

Post marketing surveillance does not suggest an effect of tramadol on fertility.

Animal studies did not show an effect of tramadol on fertility. No study on fertility was accomplished with the combination of tramadol and paracetamol

Tramadol may cause drowsiness or dizziness, which may be enhanced by alcohol or other CNS depressants. If affected, the patient should not drive or operate machinery.

The most commonly reported undesirable effects during the clinical trials performed with the paracetamol/tramadol hydrochloride combination were nausea, dizziness and somnolence, observed in more than 10 % of the patients.

 

The frequencies are defined as follows:

Very common:                                ≥1/10

Common:                                        ≥1/100 to <1/10

Uncommon:                                   ≥1/1000 to <1/100

Rare:                                                ≥1/10 000 to <1/1000

Very rare:                                       <1/10 000

Unknown:                                      Frequency cannot be estimated from the available data

 

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

 

Cardiac disorders:

·              Uncommon: palpitations, tachycardia, arrythmia.

Eye disorders:

·              Rare: vision blurred, miosis, mydriasis.

Ear and labyrinth disorders:

·              Uncommon: tinnitus.

Gastro-intestinal disorders: 

·       Very common: nausea

·       Common: vomiting, constipation, dry mouth, diarrhoea abdominal pain, dyspepsia, flatulence

·       Uncommon: dysphagia, melaena.

 

General disorders and administration site conditions:

·       Uncommon: chills, chest pain.

Investigations:

·       Uncommon: transaminases increased.

Metabolism and nutrition disorders:

·       Unknown: hypoglycaemia.

Nervous system disorders:

·              Very common: dizziness, somnolence

·              Common: headache trembling

·              Uncommon: muscle contractions involuntary, paraesthesia, amnesia

·              Rare: ataxia, convulsions, syncope, speech disorders.

 

Psychiatric disorders:

 

·       Common: confusional state, mood altered, anxiety, nervousness, euphoric mood, sleep disorders

·       Uncommon: depression, hallucinations, nightmares

·       Rare: delirium, drug dependence.

 

Post marketing surveillance Very rare: abuse.

Renal and urinary disorders:

 

·       Uncommon: albuminuria, micturition disorders (dysuria and urinary retention).

Respiratory, thoracic and mediastinal disorders:

·              Uncommon: dyspnoea.

Skin and subcutaneous tissue disorders:

·       Common: hyperhidrosis, pruritus

·       Uncommon: dermal reactions (e.g. rash, urticaria).

Vascular disorders:

·       Uncommon: hypertension, hot flush.

Although not observed during clinical trials, the occurrence of the following undesirable effects known to be related to the administration of tramadol or paracetamol cannot be excluded:

 

Tramadol

·       Postural hypotension, bradycardia, collapse (tramadol).

·       Post-marketing surveillance of tramadol has revealed rare alterations of warfarin effect, including elevation of prothrombin times.

·       Rare cases (≥ 1/10000 to < 1/1000) : allergic reactions with respiratory symptoms (e.g. dyspnoea, bronchospasm, wheezing, angioneurotic oedema) and anaphylaxis

·       Rare cases (≥ 1/10000 to < 1/1000) : changes in appetite, motor weakness, and respiratory depression

·       Psychic side-effects may occur following administration of tramadol which vary individually in intensity and nature (depending on personality and duration of medication). These include changes in mood, (usually euphoric mood occasionally dysphoria), changes in activity (usually suppression occasionally increase) and changes in cognitive and sensorial capacity (e.g. decision behaviour perception disorders).

·       Worsening of asthma has been reported though a causal relationship has not been established.

·       Symptoms of drug withdrawal syndrome, similar to those occurring during opiate withdrawal may occur as follows: agitation, anxiety, nervousness, insomnia, hyperkinesia, tremor and gastrointestinal symptoms. Other symptoms that have very rarely been seen if tramadol hydrochloride is discontinued abruptly include: panic attacks, severe anxiety, hallucinations, paraesthesia, tinnitus and unusual CNS symptoms.

 

Paracetamol

·       Adverse effects of paracetamol are rare but hypersensitivity including skin rash may occur. There have been reports of blood dyscrasias including thrombocytopenia and agranulocytosis, but these were not necessarily causally related to paracetamol.

·       There have been several reports that suggest that paracetamol may produce hypoprothrombinemia when administered with warfarin-like compounds. In other studies, prothrombin time did not change.

·       Very rare cases of serious skin reactions have been reported.

 

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation 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 <[to be completed nationally]>.

zaldiar is a fixed combination of active ingredients. In case of overdose, the symptoms may include the signs and symptoms of toxicity of tramadol or paracetamol or of both these active ingredients.

 

Symptoms of overdose from tramadol:

 

In principle, on intoxication with tramadol, symptoms similar to those of other centrally acting analgesics (opioids) are to be expected. These include in particular, miosis, vomiting, cardiovascular collapse, consciousness disorders up to coma, convulsions and respiratory depression up to respiratory arrest.

 

Symptoms of overdose from paracetamol:

An overdose is of particular concern in young children. Symptoms of paracetamol overdosage in the first 24 hours are pallor, nausea, vomiting, anorexia and abdominal pain. Liver damage may become apparent 12 to 48 hours after ingestion. Abnormalities of glucose metabolism and metabolic acidosis may occur. In severe poisoning, hepatic failure may progress to encephalophathy, coma and death. Acute renal failure with acute tubular necrosis may develop even in the absence of severe liver damage. Cardiac arrhythmias and pancreatitis have been reported.

 

Liver damage is possible in adults who have taken 7.5-10 g or more of paracetamol. It is considered that excess quantities of a toxic metabolite (usually adequately detoxified by glutathione when normal doses of paracetamol are ingested), become irreversibly bound to liver tissue.

 

Emergency treatment:

-       Transfer immediately to a specialised unit.

-       Maintain respiratory and circulatory functions

-       Prior to starting treatment, a blood sample should be taken as soon as possible after overdose in order to measure the plasma concentration of paracetamol and tramadol and in order to perform hepatic tests.

-      Perform hepatic tests at the start (of overdose) and repeat every 24 hours. An increase in hepatic enzymes (ASAT, ALAT) is usually observed, which normalizes after one or two weeks.

-      Empty the stomach by causing the patient to vomit (when the patient is conscious) by irritation or gastric lavage.

-      Supportive measures such as maintaining the patency of the airway and maintaining cardiovascular function should be instituted; naloxone should be used to reverse respiratory depression; fits can be controlled with diazepam.

-      Tramadol is minimally eliminated from the serum by haemodialysis or haemofiltration.

Therefore treatment of acute intoxication with zaldiar with haemodialysis or haemofiltration alone is not suitable for detoxification.

 

Immediate treatment is essential in the management of paracetamol overdose. Despite a lack of significant early symptoms, patients should be referred to hospital urgently for immediate medical attention and any adult or adolescent who had ingested around 7.5 g or more of paracetamol in the preceding 4 hours or any child who has ingested ³150 mg/kg of paracetamol in the preceding 4 hours should undergo gastric lavage. Paracetamol

 

concentrations in blood should be measured later than 4 hours after overdose in order to be able to assess the risk of developing liver damage (via the paracetamol overdose nomogram). Administration of oral methionine or intravenous N-acetylcysteine (NAC) which may have a beneficial effect up to at least 48 hours after the overdose, may be required. Administration of intravenous NAC is most beneficial when initiated within 8 hours of overdose ingestion.

However, NAC should still be given if the time to presentation is greater than 8 hours after overdose and continued for a full course of therapy. NAC treatment should be started immediately when massive overdose is suspected. General supportive measures must be available.

 

Irrespective of the reported quantity of paracetamol ingested, the antidote for paracetamol, NAC, should be administered orally or intravenously, as quickly as possible, if possible, within 8 hours following the overdose.

 

Pharmacotherapeutic group: Other opioids Tramadol, combinations ATC code: N02A X 52

 

ANALGESICS

Tramadol is an opioid analgesic that acts on the central nervous system. Tramadol is a pure non selective agonists of the m, d, and k opioid receptors with a higher affinity for the µ receptors. Other mechanisms which contribute to its analgesic effect are inhibition of neuronal reuptake of noradrenaline and enhancement of serotonin release. Tramadol has an antitussive effect. Unlike morphine, a broad range of analgesic doses of tramadol has no respiratory depressant effect.

Similarly, the gastro-intestinal motility is not modified. The cardiovascular effects are generally slight. The potency of tramadol is considered to be one-tenth to one-sixth that of morphine.

 

The precise mechanism of the analgesic properties of paracetamol is unknown and may involve central and peripheral effects.

 

zaldiar is positioned as a step II analgesic in the WHO pain ladder and should be utilised accordingly by the physician.

Tramadol is administered in racemic form and the [-] and [+] forms of tramadol and its metabolite M1, are detected in the blood. Although tramadol is rapidly absorbed after administration, its absorption is slower (and its half-life longer) than that of paracetamol.

 

After a single oral administration of a tramadol/paracetamol (37.5 mg/325 mg) tablet, peak plasma concentrations of 64.3/55.5 ng/ml [(+)-tramadol/(-)-tramadol] and 4.2 µg/ml (paracetamol) are reached after 1.8 h [(+)-tramadol/(-)-tramadol] and 0.9 h (paracetamol) respectively. The mean elimination half-lives t1/2 are

5.1/4.7 h [(+)-tramadol/(-)-tramadol] and 2,5 h (paracetamol).

 

During pharmacokinetic studies in healthy volunteers after single and repeated oral administration of zaldiar, no clinical significant change was observed in the kinetic parameters of each active ingredient compared to the parameters of the active ingredients used alone.

 

 

Absorption:

Racemic tramadol is rapidly and almost completely absorbed after oral administration. The mean absolute bioavailability of a single 100 mg dose is approximately 75 %. After repeated administration, the bioavailability is increased and reaches approximately 90 %.

After administration of zaldiar , the oral absorption of paracetamol is rapid and nearly complete and takes place mainly in the small intestine. Peak plasma concentrations of paracetamol are reached in one hour and are not modified by concomitant administration of tramadol.

The oral administration of zaldiar with food has no significant effect on the peak plasma concentration or extent of absorption of either tramadol or paracetamol so that <Trademark> can be taken independently of meal times.

 

Distribution:

Tramadol has a high tissue affinity (Vd,b=203 ± 40 l). It has a plasma protein binding of about 20%.

Paracetamol appears to be widely distributed throughout most body tissues except fat. Its apparent volume of distribution is about 0.9 l/kg. A relative small portion (~20%) of paracetamol is bound to plasma proteins.

 

Metabolism:

Tramadol is extensively metabolized after oral administration. About 30 % of the dose is excreted in urine as unchanged drug, whereas 60% of the dose is excreted as metabolites.

 

Tramadol is metabolised through O-demethylation (catalysed by the enzyme CYP2D6) to the metabolite M1, and through N-demethylation (catalysed by CYP3A) to the metabolite M2. M1 is further metabolised through N-demethylation and by conjugation with glucuronic acid. The plasma elimination half-life of M1 is 7 hours. The metabolite M1 has analgesic properties and is more potent than the parent drug. The plasma concentrations of M1 are several-fold lower than those of tramadol and the contribution to the clinical effect is unlikely to change on multiple dosing.

 

Paracetamol is principally metabolized in the liver through two major hepatic routes: glucuronidation and sulphation. The latter route can be rapidly saturated at doses above the therapeutic doses. A small fraction (less than 4%) is metabolized by cytochrome P 450 to an active intermediate (the N-acetyl benzoquinoneimine) which, under normal conditions of use, is rapidly detoxified by reduced glutathione and excreted in urine after conjugation to cysteine and mercapturic acid. However, during massive overdose, the quantity of this metabolite is increased.

 

Elimination:

Tramadol and its metabolites are eliminated mainly by the kidneys. The half-life of paracetamol is approximately 2 to 3 hours in adults. It is shorter in children and slightly longer in the newborn and in cirrhotic patients. Paracetamol is mainly eliminated by dose-dependent formation of glucuro- and sulpho-conjugate derivatives. Less than 9 % of paracetamol is excreted unchanged in urine. In renal insufficiency, the half-life of both compounds is prolonged.

No preclinical study has been performed with the fixed combination (tramadol and paracetamol) to evaluate its carcinogenic or mutagenic effects or its effects on fertility.

No teratogenic effect that can be attributed to the medicine has been observed in the progeny of rats treated orally with the combination tramadol/paracetamol.

The combination tramadol/paracetamol has proven to be embryotoxic and foetotoxic in the rat at materno-toxic dose (50/434 mg/kg tramadol/paracetamol), i.e., 8.3 times the maximum therapeutic dose in man. No teratogenic effect has been observed at this dose. The toxicity to the embryo and the foetus results in a decreased foetal weight and an increase in supernumerary ribs. Lower doses, causing less severe materno-toxic effect (10/87 and 25/217 mg/kg tramadol/paracetamol) did not result in toxic effects in the embryo or the foetus.

Results of standard mutagenicity tests did not reveal a potential genotoxic risk for tramadol in man.

Results of carcinogenicity tests do not suggest a potential risk of tramadol for man.

Animal studies with tramadol revealed, at very high doses, effects on organ development, ossification and neonatal mortality, associated with maternotoxicity. Fertility reproductive performance and development of offspring were unaffected. Tramadol crosses the placenta. Male and female fertility was not affected.

Extensive investigations showed no evidence of a relevant genotoxic risk of paracetamol at therapeutic (i.e. non-toxic) doses.

Long-term studies in rats and mice yielded no evidence of relevant tumorigenic effects at non- hepatotoxic dosages of paracetamol.

Animal studies and extensive human experience to date yield no evidence of reproductive toxicity.

 

Tablet core:

powdered cellulose pregelatinised starch

sodium starch glycolate (Type A) maize starch

magnesium stearate

 

Film-coating: hypromellose lactose monohydrate

titanium dioxide (E 171) macrogol 6000

yellow iron oxide (E 172) propylene glycol

talc

Not applicable.

3 years in paper/PET/aluminium-PVC blister packs.

This medicinal product does not require any special storage conditions.

zaldiar tablets are packed in paper/PET/aluminium-PVC blisters. Box of 2 tablets, of 10, 20, 30, 40, 50, 60, 70, 80, 90 and 100 tablets Not all packaging sizes may be marketed.

No special requirements.