Patient leaflet - Rivaroxaban Milpharm 15 mg film-coated tablets / Rivaroxaban Milpharm 20 mg film-coated

1. What Rivaroxaban is and what it is used for

This medicine contains the active substance rivaroxaban and is used in adults to:

Treat blood clots in the veins of your
legs (deep vein thrombosis) and in the blood vessels of your lungs (pulmonary embolism), and to prevent blood clots from re-occurring in the blood vessels of your legs and/or lungs.

Rivaroxaban belongs to a group of medicines called antithrombotic agents. It works by blocking a blood clotting factor (factor Xa) and thus reducing the tendency of the blood to form clots.

2. What you need to know before you take Rivaroxaban

Do not take Rivaroxaban:

If you are allergic to rivaroxaban or
any of the other ingredients of this medicine (listed in section 6).
If you are bleeding excessively
If you have a disease or condition in an
organ of the body that increases the risk of serious bleeding (e.g., stomach ulcer, injury or bleeding in the brain, recent surgery of the brain or eyes)
If you are taking medicines to
prevent blood clotting (e.g. warfarin, dabigatran, apixaban or heparin), except when changing anticoagulant treatment or while getting heparin through a venous or arterial line to keep it open.
- If you have a liver disease
  which leads to an increased risk of bleeding
- If you are pregnant or breast
  feeding

Do not take Rivaroxaban and tell your doctor if any of these apply to you.

Warnings and precautions

Talk to your doctor or pharmacist before taking Rivaroxaban

Take special care with Rivaroxaban

If you have an increased risk of
bleeding, as could be the case in situations such as:
- Severe kidney disease, since your
  kidney function may affect the amount of medicine that works in your body
- If you are taking other medicines
  to prevent blood clotting (e.g. warfarin, dabigatran, apixaban or heparin), when changing anticoagulant treatment or while getting heparin through a venous or arterial line to keep it open (see section “Other medicines and Rivaroxaban”)
- Bleeding disorders
- Very high blood pressure, not
  controlled by medical treatment
- Diseases of your stomach or bowel
  that might result in bleeding, e.g. inflammation of the bowels or stomach, or inflammation of the oesophagus (gullet) e.g. due to gastroesophageal reflux disease (disease where stomach acid goes upwards into the oesophagus) or tumours located in the stomach or bowels or genital tract or urinary tract
- A problem with the blood vessels in
  the back of your eyes (retinopathy)
- A lung disease where your bronchi
  are widened and filled with pus (bronchiectasis), or previous bleeding from your lung
If you have a prosthetic heart valve
If you know that you have a disease
called antiphospholipid syndrome (a disorder of the immune system that causes an increased risk of blood clots), tell your doctor who will decide if the treatment may need to be changed.
If your doctor determines that your
blood pressure is unstable or another treatment or surgical procedure to remove the blood clot from your lungs is planned.

If any of the above apply to you, tell your doctor before you take Rivaroxaban. Your doctor will decide, if you should be treated with this medicine and if you should be kept under closer observation.

If you need to have an operation:

It is very important to take Rivaroxaban
before and after the operation exactly at the times you have been told by your doctor.
If your operation involves a catheter or
injection into your spinal column (e.g.
for epidural or spinal anaesthesia or pain reduction):
- It is very important to take
  Rivaroxaban before and after the injection or removal of the catheter exactly at the times you have been told by your doctor
- Tell your doctor immediately if you get numbness or weakness of your legs or problems with your bowel or bladder after the end of anaesthesia, because urgent care is necessary.

Children and adolescents

Rivaroxaban treatment initiation pack is not recommended for people under 18 years of age as it is specifically designed for initiation of treatment in adult patients and is not appropriate for use in children and adolescents.

Other medicines and Rivaroxaban

Tell your doctor or pharmacist if you are taking, have recently taken or might take any other medicines including medicines obtained without a prescription.

If you are taking:
- Some medicines for fungal
  infections (e.g. fluconazole, itraconazole, voriconazole, posaconazole), unless they are only applied to the skin
- Ketoconazole tablets (used to treat Cushing’s syndrome – when the body produces an excess of cortisol)
- Some medicines for bacterial infections (e.g. clarithromycin, erythromycin)
- Some anti-viral medicines for HIV /
  AIDS (e.g. ritonavir)
- Other medicines to reduce
  blood clotting (e.g. enoxaparin, clopidogrel or vitamin K
  antagonists such as warfarin and acenocoumarol)
- Anti-inflammatory and pain
  relieving medicines (e.g. naproxen or acetylsalicylic acid)
- Dronedarone, a medicine to treat abnormal heart beat
- Some medicines to treat
  depression (selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs))

If any of the above apply to you, tell your doctor before taking Rivaroxaban, because the effect of Rivaroxaban may be increased. Your doctor will decide, if you should be treated with this medicine and if you should be kept under closer observation.

If your doctor thinks that you are at increased risk of developing stomach or bowel ulcers, he may also use a preventative ulcer treatment.

If you are taking:
- Some medicines for treatment of epilepsy (phenytoin,
  carbamazepine, phenobarbital)
- St John’s Wort (Hypericum
  perforatum), a herbal product used for depression
- Rifampicin, an antibiotic

If any of the above apply to you, tell your doctor before taking Rivaroxaban, because the effect of Rivaroxaban may be reduced. Your doctor will decide, if you should be treated with Rivaroxaban and if you should be kept under closer observation.

Pregnancy, breast-feeding and fertility

Do not take Rivaroxaban if you are pregnant or breast feeding. If there is a chance that you could become pregnant, use a reliable contraceptive while you are taking Rivaroxaban. If you become pregnant while you are taking this medicine, tell your doctor immediately, who will decide how you should be treated.

Driving and using machines

Rivaroxaban may cause dizziness (common side effect) or fainting (uncommon side effect) (see section 4. ‘Possible side effects’). You should not drive, ride a bicycle or use any tools or machines if you are affected by these symptoms.

Rivaroxaban contains lactose and sodium

If you have been told by your doctor that you have an intolerance to some sugars, contact your doctor before taking this medicine.

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

3. How to take Rivaroxaban

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

You must take Rivaroxaban together with a meal.

Swallow the tablet(s) preferably with water.

If you have difficulty swallowing the tablet whole, talk to your doctor about other ways to take Rivaroxaban. The tablet may be crushed and mixed with water or apple puree immediately before you take it. This mixture should be immediately followed by food.

If necessary, your doctor may also give you the crushed Rivaroxaban tablet through a stomach tube.

How much to take

The recommended dose is one 15 mg tablet twice a day for the first 3 weeks. For treatment after 3 weeks, the recommended dose is one 20 mg tablet once a day.
This Rivaroxaban 15 mg and 20 mg treatment initiation pack is only for the first 4 weeks of treatment.
Upon completion of this pack,
treatment will continue on Rivaroxaban 20 mg once daily as your doctor has told you.
If you have kidney problems, your doctor may decide to reduce the dose for the treatment after 3 weeks to one 15 mg tablet once a day if the risk for bleeding is greater than the risk for having another blood clot.

When to take Rivaroxaban

Take the tablet(s) every day until your doctor tells you to stop.

Try to take the tablet(s) at the same time every day to help you to remember it. Your doctor will decide how long you must continue treatment.

If you take more Rivaroxaban than you should

Contact your doctor immediately if you have taken too many Rivaroxaban tablets. Taking too much Rivaroxaban increases the risk of bleeding.

If you forget to take Rivaroxaban

If you are taking one 15 mg tablet
twice a day and have missed a dose, take it as soon as you remember. Do not take more than two 15 mg tablets in a single day. If you forget to take a dose you can take two 15 mg tablets at the same time to get a total of two tablets (30 mg) on one day. On the following day you should carry on taking one 15 mg tablet twice a day.
If you are taking one 20 mg tablet once
a day and have missed a dose, take it as soon as you remember. Do not take more than one tablet in a single day to make up for a forgotten dose. Take the next tablet on the following day and then carry on taking one tablet once a day.

If you stop taking Rivaroxaban

Do not stop taking Rivaroxaban without talking to your doctor first, because Rivaroxaban treats and prevents serious conditions.

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

4. Possible side effects

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

Like other similar medicines to reduce the formation of blood clots, Rivaroxaban may cause bleeding which may potentially be life threatening. Excessive bleeding may lead to a sudden drop in blood pressure (shock). In some cases the bleeding may not be obvious.

Tell your doctor immediately if you experience any of the following side effects:

Signs of bleeding
bleeding into the brain or inside
the skull (symptoms can include headache, one-sided weakness, vomiting, seizures, decreased level of consciousness, and neck stiffness. A serious medical emergency. Seek medical attention immediately!):
Long or excessive bleeding
Exceptional weakness, tiredness,
paleness, dizziness, headache, unexplained swelling, breathlessness, chest pain or angina pectoris.

Your doctor may decide to keep you under closer observation or change the treatment.

Signs of severe skin reactions
Spreading intense skin rash,
blisters or mucosal lesions, e.g. in the mouth or eyes (Stevens-Johnson syndrome/toxic epidermal necrolysis).
A drug reaction that causes
rash, fever, inflammation of internal organs, blood abnormatlities and systemic illness (DRESS syndrome). The frequency of these side effects is very rare (up to 1 in 10,000 people).
Signs of severe allergic reactions
Swelling of the face, lips, mouth,
tongue or throat; difficulty swallowing; hives and breathing difficulties; sudden drop in blood pressure.

The frequencies of severe allergic reactions are very rare (anaphylactic reactions, including anaphylactic shock; may affect up to 1 in 10,000 people) and uncommon (angioedema and allergic oedema; may affect up to 1 in 100 people).

Overall list of possible side effects:

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

Reduction in red blood cells which
can make the skin pale and cause weakness or breathlessness
Bleeding in the stomach or bowel,
urogenital bleeding (including blood in the urine and heavy menstrual bleeding), nose bleed, bleeding in the gum
Bleeding into the eye (including
bleeding from the whites of the eyes)
Bleeding into tissue or a cavity of the
body (haematoma, bruising)
Coughing up blood
Bleeding from the skin or under the
skin
Bleeding following an operation
Oozing of blood or fluid from surgical
wound
Swelling in the limbs
Pain in the limbs
Impaired function of the kidneys (may
be seen in tests performed by your doctor)
Fever
Stomach ache, indigestion, feeling or
being sick, constipation, diarrhoea
Low blood pressure (symptoms may
be feeling dizzy or fainting when standing up)
Decreased general strength and
energy (weakness, tiredness), headache, dizziness
Rash, itchy skin
Blood tests may show an increase in
some liver enzymes

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

Bleeding into the brain or inside the
skull (see above, signs of bleeding)
Bleeding into a joint causing pain and
swelling
Thrombocytopenia (low number of
platelets, which are cells that help blood to clot)
- Allergic reactions, including allergic skin reactions
- Impaired function of the liver (may be seen in tests performed by your doctor)
- Blood tests may show an increase in bilirubin, some pancreatic or liver enzymes or in the number of platelets
- Fainting
- Feeling unwell
- Faster heartbeat
- Hives

Rare (may affect up to 1 in 1,000 people):

Bleeding into a muscle
Cholestasis (decreased bile flow), hepatatis incl. hepatocellular injury (inflamed liver incl. liver injury)
Yellowing of the skin and eye
(jaundice)
Localised swelling
Collection of blood (haematoma) in the groin as a complication of the cardiac procedure where a catheter is inserted in your leg artery (pseudoaneurysm)

Very rare (may affect up to 1 in 10,000 people)

accumulation of eosinophils, a type of white granulocytic blood cells that cause inflammation in the lung (eosinophilic pneumonia)

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

Kidney failure after a severe bleeding
Bleeding in the kidney sometimes with presence of blood in urine leading to inability of the kidneys to work properly (anticoagulant-related nephropathy)
Increased pressure within muscles of the legs or arms after a bleeding, which leads to pain, swelling, altered sensation, numbness or paralysis (compartment syndrome after a bleeding)

Reporting of side effects

If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. You can also report side effects directly via Yellow Card Scheme Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store

By reporting side effects you can help provide more information on the safety of this medicine.

5. How to store Rivaroxaban

Keep this medicine out of the sight and reach of children.

Do not use this medicine after the expiry date which is stated on the carton, blister after “EXP”.The expiry date refers to the last day of that month.

This medicine does not require any special storage conditions.

Crushed tablets

Crushed tablets are stable in water or apple puree for up to 4 hours.

Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to throw away medicines you no longer use. These measures will help protect the environment.

6. Contents of the pack and other information

What Rivaroxaban contains

The active substance is rivaroxaban.
Each tablet contains 15 mg and 20 mg of rivaroxaban.
The other ingredients are:
Tablet core: Cellulose, Microcrystalline
(Grade-101 and Grade-102), lactose monohydrate, croscarmellose sodium, hypromellose type 2910 (3 cPs), sodium laurilsulfate, magnesium stearate Tablet coating: Polivinyl alcohol, macrogol 3350, talc, titanium dioxide (E171), iron oxide red (E172)

What Rivaroxaban looks like and contents of the pack

Film-coated tablet.

Rivaroxaban 15 mg:

Red, round (diameter: 6.1 mm), biconvex film-coated tablet with ‘M’ on one side and ‘15’on the other side.

Rivaroxaban 20 mg:

Dark red to brown red, oval, biconvex film-coated tablet with ‘M’ on one side and ‘20’on the other side.

The size is 8.1 x 4.6 mm.

First 4 weeks treatment initiation pack:

Each pack of 49 film-coated tablets for the first 4 weeks of treatment contains: 42 film-coated tablets of 15 mg

rivaroxaban and 7 film-coated tablets of 20 mg rivaroxaban.

Marketing Authorisation Holder

Milpharm Limited

Ares Block, Odyssey Business Park West End Road

Ruislip HA4 6QD

United Kingdom

Manufacturer

APL Swift Services (Malta) Limited HF26, Hal Far Industrial Estate, Hal Far, Birzebbugia, BBG 3000

Malta