Summary of medicine characteristics - BEECHAMS ULTRA ALL IN ONE CAPSULES HARD
1 NAME OF THE MEDICINAL PRODUCT
Paracetamol, Guaifenesin, Phenylephrine Hydrochloride Wrafton 500mg/100mg/6.1mg Capsules, hard.
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
Active Ingredient mg/Capsule
Paracetamol
Guaifenesin
Phenylephrine hydrochloride
For a full list of excipients, see section 6.1.
3 PHARMACEUTICAL FORM
Capsule, hard.
Dark blue/dark green hard gelatin capsules containing the drug product, an off-white powder.
4 CLINICAL PARTICULARS
4.1 Therapeutic indications
For the relief of symptoms associated with colds and flu and the pain and congestion of sinusitis, including aches and pains, headache, blocked nose and sore throat, chills, lowering of temperature, and to loosen stubborn mucous and provide relief from chesty coughs.
4.2 Posology and method of administration
Route of administration: Oral.
Take capsules with water. Swallow whole, do not chew. For all indications:
Adults, the elderly and children aged 16 years and over:
Two capsules every 4–6 hours when necessary to a maximum of 4 doses in 24 hours.
Children under 16 years:
Do not give to children under 16 years of age.
Dosage should not be continued for longer than 3 days without consulting a doctor.
4.3 Contraindications
Hypersensitivity to paracetamol, guaifenesin or phenylephrine or any of the other ingredients.
Hepatic or severe renal impairment, hypertension, hyperthyroidism, diabetes, heart disease or those taking tricyclic antidepressants or beta-blocking drugs and those patients who are taking or have taken, within the last two weeks, monoamine oxidase inhibitors (see section 4.5).
Phaeochromocytoma.
Prostatic enlargement or urinary retention.
Use in patients with closed angle glaucoma. -
Use in patients who are currently receiving other sympathomimetic drugs (see
Section 4.5)
Pregnancy (see Section 4.6) Porphyria.
4.4 Special warnings and precautions for use
The hazards of overdose are greater in those with non-cirrhotic alcoholic liver disease.
Use with caution in patients with circulatory disorders such as Raynaud’s
Phenomenon. –
Patients with prostatic hypertrophy may have increased difficulty with micturition.
Sympathomimetic-containing products may act as cerebral stimulants giving rise to insomnia, nervousness, hyperpyrexia, tremor and epileptiform convulsions.
This product should not be used by patients taking other sympathomimetics (such as decongestants, appetite suppressants and amphetamine-like psychostimulants).
Patients suffering from chronic cough or asthma should consult a physician before taking this product. Patients should stop using the product and consult a health care professional if cough lasts for more than 5 days or comes back, or
is accompanied by a fever, rash or persistent headache.
Do not take with a cough suppressant. If symptoms persist consult your doctor.
Do not take with alcohol.
Special label warnings
If you are taking medication or are under medical care, consult your doctor before using this medicine. Do not take with any other flu, cold or decongestant products. Do not take more medicine than the label tells you to. If you do not get better, talk to your doctor.
Keep out of the sight and reach of children.
Contains paracetamol. Do not take anything else containing paracetamol while taking this medicine. Talk to a doctor at once if you take too much of this medicine even if you feel well.
Special leaflet warnings
Do not take more medicine than the label tells you to. If you do not get better, talk to your doctor.
Keep this medicine out of the sight and reach of children.
Contains paracetamol. Do not take anything else containing paracetamol while taking this medicine. Talk to a doctor at once if you take too much of this medicine even if you feel well. This is because too much paracetamol can cause delayed, serious liver damage.
If you are taking medication or are under medical care, consult your doctor before using this medicine. Do not take with any other flu, cold or decongestant products.
4.5 Interaction with other medicinal products and other forms of interaction
PARACETAMOL
The speed of absorption of paracetamol may be increased by metoclopramide or domperidone and absorption reduced by colestyramine.
The anticoagulant effect of warfarin and other coumarins may be enhanced by prolonged regular use of paracetamol with increased risk of bleeding, although occasional doses have no significant effect.
Drugs which induce hepatic microsomal enzymes, such as alcohol, barbiturates, monoamine oxidase inhibitors and tricyclic antidepressants, may increase the hepatotoxicity of paracetamol particularly after overdosage. Contraindicated in patients currently receiving or within two weeks of stopping therapy with monoamine oxidase inhibitors because of a risk of hypertensive crisis.
PHENYLEPHRINE HYDROCHLORIDE
Phenylephrine may adversely interact with other sympathomimetics, vasodilators and beta blockers. Concomitant use of phenylephrine with other sympathomimetic amines can increase the risk of cardiovascular side effects.
Hypertensive interactions occur between sympathomimetic amines such as phenylephrine and monoamine oxidase inhibitors.
Phenylephrine should be used with caution in combination with Ergot alkaloids (ergotamine and methysergide), increase risk of ergotism. Concomitant use of phenylephrine with other sympathomimetic amines can increase the risk of cardiovascular side effects. Hypertensive interactions occur between sympathomimetic amines such as phenylephrine and monoamine oxidase inhibitors.
Sympathomimetic-containing products should be used with great care in patients receiving phenothiazines or tricylic antidepressants. May increase the risk of cardiovascular side effects with phenylephrine.
Phenylephrine should be used with caution in combination with Ergot alkaloids (ergotamine and methysergide), increase risk of ergotism.
Sympathomimetic-containing products should be used with caution in patients receiving digitalis (digoxin and cardiac glycosides), beta-adrenergic blockers, guanethidine, reserpine, debrisoquine, methyldopa or anti-hypertensive agents.
Phenylephrine may reduce the efficacy of beta-blocking drugs and antihypertensive drugs. The risk of hypertension and other cardiovascular
side effects may be increased.
Concurrent use with halogenated anesthetic agents such as chloroform, cyclopropane, halothane, enflurane or isoflurane may provoke or worsen ventricular arrhythmias.
This medicine should not be used with enzyme inducers such as alcohol.
GUAIFENESIN
If urine is collected within 24 hours of a dose of this product a metabolite of guaifenesin may cause a colour interference with laboratory determinations of urinary-5-hydroxyindolacetic acid (5-HIAA) and vanillylmandelic acid (VMA).
4.6 Fertility, Pregnancy and lactation
PARACETAMOL
Epidemiological studies in human pregnancy have shown no ill effects due to paracetamol used in the recommended dosage, but patients should follow the advice of their doctor regarding its use.
Paracetamol is excreted in breast milk but not in a clinically significant amount. Available published data do not contraindicate breast feeding.
GUAIFENESIN
The safety of guaifenesin in pregnancy and lactation has not been fully established but this constituent is not thought to be hazardous. However the product should only be used in pregnancy when considered essential by the doctor.
PHENYLEPHRINE HYDROCHLORIDE
The safety of this medicine during pregnancy and lactation has not been established but in view of a possible association of foetal abnormalities with first trimester exposure to phenylephrine, the use of the product during pregnancy should be avoided.
Phenylephrine should not be taken during pregnancy as it has been reported to cause foetal hypoxia.
Due to the vasconstrictive properties of phenylephrine, the product should be used with caution in patients with a history of pre-eclampsia. Phenylephrine may reduce placental perfusion and the product should be used in pregnancy only if the benefits outweigh this risk. There is no information on use in lactation.
In view of the lack of data on the use of phenylephrine during lactation, this medicine should not be used during breast feeding. Excretion in breast milk is reported to be minimal.
4.7 Effects on ability to drive and use machines
Patients should be advised not to drive or operate machinery if affected by dizziness.
4.8 Undesirable effects
Adverse events from historical clinical trial data are both infrequent and from small patient exposure. Events reported from extensive post-marketing experience at therapeutic/labelled dose and considered attributable are tabulated below by MedDRA System Organ Class. Due to limited clinical trial data, the frequency of these adverse events is not known (cannot be estimated from available data), but post-marketing experience indicates that adverse reactions to paracetamol are rare and serious reactions are very rare.
Thrombocytopenia, Agranulocytosis
These are not necessarily causally related to paracetamol
Anaphylaxis, Cutaneous hypersensitivity reactions including skin rashes, angioedema and Stevens Johnson syndrome, toxic epidermal necrolysis
Bronchospasm*
Gastrointestinal disorders Acute pancreatitis * There have been cases of bronchospasm with paracetamol, but these are more likely in asthmatics sensitive to aspirin or other NSAIDs.
The following adverse events have been observed in clinical trials with phenylephrine and may therefore represent the most commonly occurring adverse events.
Nervousness, irritability, restlessness, and excitability
Headache, dizziness, insomnia
Increased blood pressure
Nausea, Vomiting, diarrhoea
Adverse reactions identified during post marketing use are listed below. The frequency of these reactions is unknown but likely to be rare.
Mydriasis, acute angle closure glaucoma, most likely to occur in those with closed angle glaucoma
Tachycardia, palpitations
Allergic reactions (e.g. rash, urticaria, allergic dermatitis). Hypersensitivity reactions including cross-sensitivity with other sympathomimetics may occur.
Dysuria, urinary retention. This is most likely to occur in those with bladder outlet obstruction, such as prostatic hypertrophy.
The frequency of these events is unknown but considered likely to be rare.
Allergic reactions, angioedema, anaphylactic reactions
Dyspnoea
Nausea, vomiting, abdominal discomfort
Rash, urticarial
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 the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.
4.9 Overdose
PARACETAMOL
There is a risk of poisoning, particularly in elderly subjects, in young children, in patients with liver disease, in cases of chronic alcoholism, in patients with chronic malnutrition. Overdosing may be fatal in these cases. Symptoms generally appear within the first 24 hours and comprise: nausea, vomiting, anorexia, pallor, and abdominal pain.
Overdose of paracetamol in a single administration in adults or in children causes liver cell necrosis likely to induce complete and irreversible necrosis, resulting in hepatocellular insufficiency, metabolic acidosis and encephalopathy which may lead to coma and death. Simultaneously, increased levels of hepatic transaminases (AST, ALT), lactate dehydrogenase and bilirubin are observed together with increased prothrombin levels that may appear 12 to 48 hours after administration.
Liver damage is likely in adults who have taken more than the recommended amounts of paracetamol. It is considered that excess quantities of toxic metabolite (usually adequately detoxified by glutathione when normal doses of paracetamol are ingested), become irreversibly bound to liver tissue.
Some patients may be at increased risk of liver damage from paracetamol toxicity.
Risk Factors
If the patient
a) is on long term treatment with carbamazepine, phenobarbital, phenytoin, primidone, rifampicin, St John’s Wort or other drugs that induce liver enzymes.
b) Regularly consumes ethanol in excess of recommended amounts.
or
c) Is likely to be glutathione deplete e.g. eating disorders, cystic fibrosis, HIV infection, starvation, cachexia.
Symptoms
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 encephalopathy, haemorrhage, hypoglycaemia, cerebral oedema, and death. Acute renal failure with acute tubular necrosis, strongly suggested by loin pain, haematuria and proteinuria, may develop even in the absence of severe liver damage. Cardiac arrhythmias and pancreatitis have been reported.
Management
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. Symptoms may be limited to nausea or vomiting and may not reflect the severity of overdose or the risk of organ damage. Management should be in accordance with established treatment guidelines, see British National Formulary (BNF) overdose section.
Treatment with activated charcoal should be considered if the overdose has been taken within one hour. Plasma paracetamol concentration should be measured at four hours or later after ingestion (earlier concentrations are unreliable). Treatment with N-acetylcysteine, may be used up to 24 hours after ingestion of paracetamol, however, the maximum protective effect is obtained up to eight hours post-ingestion.
The effectiveness of the antidote declines sharply after this time. If required the patient should be given intravenous N-acetylcysteine, in line with the established dosage schedule. If vomiting is not a problem, oral methionine may be a suitable alternative for remote areas, outside hospital. Management of patients who present with serious hepatic dysfunction beyond 24 hours from ingestion should be discussed with the National Poisons Information Service (NPIS) or a liver unit.
GUAIFENESIN
Gastrointestinal discomfort has occasionally been reported with Guaifenesin. Very large doses of guaifenesin can cause nausea and vomiting. Vomiting should be treated by fluid replacement and monitoring of electrolytes.
PHENYLEPHRINE HYDROCHLORIDE
Phenylephrine hydrochloride may elevate blood pressure with headache, vomiting and rarely palpitations, tachycardia or reflex bradycardia, tingling and coolness of the skin. There have been rare reports of allergic reactions.
Symptoms of overdosage include irritability, palpitations, hypertension, difficulty in micturition, nausea, vomiting, thirst and convulsions.
Severe overdosage of phenylephrine may produce hypertension and associated reflex bradycardia, haemodynamic changes and cardiovascular collapse with respiratory depression.
Treatment measures include early gastric lavage and symptomatic and supportive measures. The hypertensive effects may be treated with an alphareceptor blocking agent (such as phentolamine mesylate 6 – 10 mg) given intravenously, and the bradycardia treated with atropine, preferably only after the pressure has been controlled. In severe overdosage gastric lavage and aspiration should be performed. Symptomatic and supportive measures should be undertaken, particularly with regard to cardiovascular and respiratory systems. Convulsions should be controlled with intravenous diazepam. Chlorpromazine may be used to control marked excitement and hallucinations. Severe hypertension may need to be treated with an alpha-adrenoreceptor blocking drug, such as phentolamine. A beta blocker may be required to control cardiac arrhythmias.
Phenylephrine overdosage is likely to result in effects similar to those listed under adverse reactions. In severe cases confusion, hallucinations, seizures and
arrhythmias may occur. However the amount required to produce serious phenylephrine toxicity would be greater than required to cause paracetamol related toxicity.
5 PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic Group:
ATC code:
Other analgesics and antipyretics &
Other cold combination preparations
N02BE51
PARACETAMOL
Analgesic:
The mechanism of analgesic action has not been fully determined. Paracetamol may act predominantly by inhibiting a prostaglandin synthesis in the central nervous system (CNS) and to a lesser extent through a peripheral action by blocking painimpulse generation. The peripheral action may also be due to inhibition of prostaglandin synthesis or to inhibition of the synthesis or actions of other substances that sensitise pain receptors to mechanical or chemical stimulation.
Antipyretic:
Paracetamol probably produces antipyresis by acting on the hypothalamic heatregulating centre to produce peripheral vasodilation resulting in increased blood flow through the skin, sweating and heat loss. The central action probably involves inhibition of prostaglandin synthesis in the hypothalamus.
GUAIFENESIN
Guaifenesin is a well known expectorant. Such expectorants are known to increase the volume of secretions in the respiratory tract and therefore to facilitate their removal by cilary action and coughing.
PHENYLEPHRINE HYDROCHLORIDE
Sympathomimetic amines, such as phenylephrine, act on alpha-adrenergic receptors of the respiratory tract to produce vasoconstriction, which temporarily reduces the swelling associated with inflammation of the mucous membranes lining the nasal and sinus passages. This allows the free drainage of the sinusoidal fluid from the sinuses.
In addition to reducing mucosal lining swelling, decongestants also suppress the production of mucous, therefore preventing a build up of fluid within the cavities which could otherwise lead to pressure and pain.
5.2 Pharmacokinetic properties
5.2 Pharmacokinetic propertiesPARACETAMOL
Absorption and Fate
Paracetamol is rapidly absorbed from the gastro-intestinal tract with peak plasma concentrations occurring between 10 and 120 minutes after oral administration. It is metabolised in the liver and excreted in the urine mainly as the glucuronide and sulphate conjugates. Less than 5% is excreted as unchanged paracetamol. The elimination half-life varies from about 1 to 4 hours.
Plasma-protein binding is negligible at usual therapeutic concentrations but increases with increasing concentrations.
A minor hydroxylated metabolite which is usually produced in very small amounts by mixed-function oxidases in the liver and which is usually detoxified by conjugation with liver glutathione may accumulate following paracetamol overdose and cause liver damage.
GUAIFENESIN
Guaifenesin is rapidly absorbed after oral administration. It is rapidly metabolised by oxidation to ß-(2 methoxy-phenoxy)lactic acid, which is excreted in the urine.
PHENYLEPHRINE HYDROCHLORIDE
Phenylephrine hydrochloride is irregularly absorbed from the gastrointestinal tract and undergoes first-pass metabolism by monoamine oxidase in the gut and liver; orally administered phenylephrine thus has reduced bioavailability. It is excreted in the urine almost entirely as the sulphate conjugate.
5.3 Preclinical safety data
There are no preclinical data of relevance to the prescriber additional to that already covered in other sections of the SPC.
6 PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Maize starch
Croscarmellose sodium
Sodium laurilsulfate
Magnesium stearate
Talc
Gelatin capsule:
Gelatin
Quinoline yellow E104
Indigo carmine E132
Erythrosine E127
Titanium dioxide E171
6.2 Incompatibilities
None known.
6.3 Shelf life
36 months
6.4 Special precautions for storage
Do not store above 25°C.
6.5 Nature and contents of container
Child Resistant blister comprising 250 micron PVC lidded with 35 gsm paper/9 micron aluminium foil.
Pack sizes of 8 and 16 capsules are available.
6.6 Special precautions for disposal
6.6 Special precautions for disposalNone.