Document: Clindamycin Actavis capsule, hard ENG SmPC change

• Clindamycin Actavis capsule, hard SmPC
• Clindamycin Actavis capsule, hard ENG SmPC

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SUMMARY OF PRODUCT CHARACTERISTICS

1. NAME OF THE MEDICINAL PRODUCT

Clindamycin Actavis 150 mg hard capsules

Clindamycin Actavis 300 mg hard capsules

2. QUALITATIVE AND QUANTITATIVE COMPOSITION

Each capsule contains clindamycin hydrochloride equivalent to 150 mg clindamycin.

Each capsule contains clindamycin hydrochloride equivalent to 300 mg clindamycin.

UExcipient with known effect:

One capsule contains 33.9 mg anhydrous lactose (see section 4.4).

One capsule contains 67.8 mg anhydrous lactose (see section 4.4).

For the full list of excipients, see section 6.1.

3. PHARMACEUTICAL form

Hard capsule

Size '1' (19.3 mm) hard gelatin capsule with opaque white cap and opaque white body imprinted with 'A714' on cap with black ink.

Size '0' (21.4 mm) hard gelatin capsule with opaque white cap and opaque white body imprinted with 'A718' on cap with black ink.

4. Clinical particulars

4.1 Therapeutic indications

Clindamycin Actavis is indicated for the treatment of the following infections in adults and children (see sections 4.4 and 5.1):

- Intra-abdominal infections

- Serious infections caused by anaerobic bacteria

- Skin and soft tissue infections

- Tonsillitis

- Dental infections

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

4.2 Posology and method of administration

Posology

Adults:

150 to 300 mg 3-4 times daily.

Elderly:

Dosage requirements in elderly patients should not be influenced by age alone.

Children:

15 mg/kg/24 hours in 3 divided doses.

Children weighing 30-45 kg can be given 150 mg 3 times daily.

The maximum dose is 20 mg/kg/ 24 hours. This dose should be administered 4 times daily.

Clindamycin Actavis capsules are not suitable for children who cannot swallow the capsules whole or where an appropriate dosage is not possible with the available strengths. It may be necessary to use an alternative formulation of clindamycin.

Dosage in hepatic impairment:
In patients with moderate to severe hepatic impairment, elimination half-life of clindamycin is prolonged. A reduction in dosage is generally not necessary if clindamycin is administered every 8 hours. However, the plasma concentration of clindamycin should be monitored in patients with severe hepatic impairment. Depending on the results, this measure can make a reduction in dosage or an increase in the dose intervals necessary.

Dosage in renal impairment:
No dose adjustment is necessary in patients with mild to moderate impairment of renal function. In patients with severe renal impairment or anuria, plasma concentration should be monitored. Depending on the results, this measure can make a reduction in dosage or an increase in the dose interval of 8 or even 12 hours necessary.

UMethod of Administration

Clindamycin capsules are given orally. Clindamycin Actavis capsules should always be swallowed whole with a full glass of water whilst in an upright position (i.e. sitting or standing).

The capsules must not be opened due to the risk of oesophageal injury.

Absorption of Clindamycin Actavis is not appreciably modified by the presence of food.

4.3 Contraindications

Clindamycin Actavis is contra-indicated in patients previously found to be sensitive to clindamycin, lincomycin or to any of the excipients listed in section 6.1.

4.4 Special warnings and precautions for use

Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of Clostridium difficile. This has been reported with use of nearly all antibacterial agents, including clindamycin. Clostridium difficileproduces toxins A and B which contribute to the development of Clostridium difficileassociated diarrhea (CDAD) and is a primary cause of “antibiotic-associated colitis”.

It is important to consider the diagnosis of CDAD in patients who present with diarrhea subsequent to the administration of antibacterial agents. This may progress to colitis, including pseudomembranous colitis (see Section 4.8), which may range from mild to fatal colitis. If antibiotic-associated diarrhoea or antibiotic-associated colitis is suspected or confirmed, ongoing treatment with antibacterial agents, including clindamycin, should be discontinued and adequate therapeutic measures should be initiated immediately. Drugs inhibiting peristalsis are contraindicated in this situation.

Clindamycin is generally not active against aerobic Gram-negative bacteria. As needed, clindamycin should be administered in conjunction with an antibacterial agent that is active against aerobic Gram-negative bacteria.

Clindamycin does not penetrate the blood/brain barrier in therapeutically effective quantities.

Since clindamycin does not diffuse adequately into cerebrospinal fluid, the drug should not be used in the treatment of meningitis.

If therapy is prolonged, liver and kidney function tests should be performed.Plasma concentration monitoring is recommended for patients with severe renal or hepatic impairment who may need a reduction in dose or an increase of the dosage interval.

The use of clindamycin may result in overgrowth of non-susceptible organisms, particularly yeasts.

Clindamycin Actavis capsules contain lactose.Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose galactose malabsorption should not take this medicine.

4.5 Interaction with other medicinal products and other forms of interaction

Clindamycin administered by injection has been shown to have neuromuscular blocking properties that may enhance the action of other neuromuscular blocking agents. It should be used with caution, therefore, in patients receiving such agents.

Antagonism has been demonstrated between clindamycin and erythromycin in vitro. Due to the possible clinical significance, these two medicinal products should not be administered concomitantly.

Vitamin K antagonists

Increased coagulation tests (PT/INR) and/or bleeding, have been reported in patients treated with clindamycin in combination with a vitamin K antagonist (e.g. warfarin, acenocoumarol and fluindione). Coagulation tests, therefore, should be frequently monitored in patients treated with vitamin K antagonists.

4.6 Fertility, pregnancy and lactation

UPregnancy

Oral and subcutaneous reproductive toxicity studies in rats and rabbits revealed no evidence of impaired fertility or harm to the fetus due to clindamycin, except at doses that caused maternal toxicity. Animal reproduction studies are not always predictive of human response.

Clindamycin crosses the placenta in humans. After multiple doses, amniotic fluid concentrations were approximatley 30 % of maternal blood concentrations.

In clinical trials with pregnanat women, the systemic administration of clindamycin during the second and third trimesters has not been associated with an increased frequency of congenital abnormalities. There are no adequate and well-controlled studies in pregnanat women during the first trimester of pregnancy.

Clindamycin should be used in pregnancy only if clearly needed.

ULactation

Orally and parentally administered clindamycin has been reported to appear in human breast milk in ranges from 0.7 to 3.8 μg/mL. Because of the potential for serious adverse reactions in nursing infants, clindamycin should not be taken by nursing mothers.

Fertility

Fertility studies in rats treated orally with clindamycin revealed no effects on fertility or mating ability.

4.7 Effects on ability to drive and use machines

Clindamycin has no or negligible influence on the ability to drive and use machines.

4.8 Undesirable effects

The table below lists the adverse reactions identified through clinical trial experience and post-marketing surveillance by system organ class and frequency.

Adverse reactions identified from post-marketing experience are included in italics. The frequency grouping is defined using the following convention:

Very common (≥ 1/10);

Common (≥ 1/100 to < 1/10);

Uncommon (≥ 1/1,000 to < 1/100);

Rare (≥ 1/10,000 to < 1/1,000);

Very Rare (< 1/10,000);

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	Very Common ≥ 1/10	Common ≥ 1/100 to < 1/10	Uncommon ≥ 1/1,000 to < 1/100	Rare ≥ 1/10,000 to < 1/1,000	Very Rare < 1/10,000	Not Known (cannot be estimated from available data)
Infections and infestations						Vaginal infection
Blood and Lymphatic System Disorders						Agranulocytosis Leukopenia Neutropenia Thrombocytopenia Eosinophilia
Immune System Disorders						Anaphylactoid reaction Drug reaction with eosinophilia and systemic symptom (DRESS)
Nervous System Disorders						Dysgeusia
Gastrointestinal Disorders		Abdominal pain Diarrhoea Pseudomembranous colitis (see section 4.4)	Nausea Vomiting			Oesophageal ulcer Oesophagitis
Hepatobiliary Disorders		Liver function test abnormal				Jaundice
Skin and Subcutaneous Tissue Disorders			Rash maculopap ular Urticaria			Toxic epidermal necrolysis Stevens-Johnson syndrome Acute generalised exanthematous pustulosis (AGEP) Erythema multiforme Dermatitis exfoliative Dermatitis bullous Rash morbilliform Pruritis

UReporting 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 the national reporting system listed in 1TUAppendix V.

4.9 Overdose

Hemodialysis and peritoneal dialysis are not effective in removing clindamycin from the serum.

5. PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Lincosamides, ATC code: J01FF01

Mechanism of action

Clindamycin is a lincosamide antibiotic with a primarily bacteriostatic action against Gram-positive aerobes and a wide range of anaerobic bacteria. Lincosamides such as clindamycin bind to the 50S subunit of the bacterial ribosome similarly to macrolides such as erythromycin and inhibit the early stages of protein synthesis. The action of clindamycin is predominantly bacteriostatic although high concentrations may be slowly bactericidal against sensitive strains.

Mechanism of resistance

Resistance to clindamycin usually occurs via macrolide-lincosamide-streptogramin B (MLS_B) type of resistance, which may be constitutive or inducible.

Breakpoints

The minimum inhibitory concentration (MIC) breakpoints determined by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) are as follows:

Staphylococci: sensitive ≤ 0.25 resistant > 0.5

Streptococci ABCG and pneumoniae: sensitive ≤ 0.5 resistant > 0.5

Gram positive anaerobes: sensitive ≤ 4 resistant > 4

Gram negative anaerobes: ≤ 4 resistant > 4

Susceptibility

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

In vitro susceptibility of micro-organsims to clindamycin

Commonly Susceptible Species Species for which acquired resistance may be a problem Gram –positive aerobes Staphylococcus aureus* Staphylococcus epidermidis Streptococcus pneumonia Streptococcus pyogenes Streptococcus viridans Anaerobes Bacteriodes fragilis group Bacteroides melaninogenicus Bifidobacterium spp. Clostridium perfringens Eubacterium spp. Fusobacterium spp. Peptococcus spp. Peptostreptococcus spp. Propionibacterium spp. Veillonella spp.

Commonly resistant organisms Clostridium difficile Enterococcus spp. Enterobacteriaceae

* Up to 50% of methicillin-susceptible S.aureushave been reported to be resistant to clindamycin in some areas. More than 90 % of methicillin –resistant S.aureus (MRSA) are resistant to clindamycin and it should not be used while awaiting susceptibility test results if there is any suspicion of MRSA.

5.2. Pharmacokinetic properties

UGeneral characteristics of active substance

Absorption
After oral administration clindamycin is absorbed quickly and almost completely (> 90%). The absorption is not affected by food. The peak plasma concentration is achieved within approximately 45 minutes after oral administration. The bioavailability is non-linear and decreases with increasing doses. Following a 600 mg dose the absolute bioavailability is 53±14%.

Distribution
Clindamycin is widely distributed in body fluids and tissues. It diffuses across the placenta but not the healthy blood-brain barrier. 68 – 93 % of clindamycin in the circulation is bound to plasma proteins. Clindamycin is distributed very highly intracellular due to the lipophilic properties. The intracellular concentrations are 10-50 times higher than the extracellular concentrations.

Metabolism

Clindamycin undergoes metabolism, presumably in the liver, to the active N-demethyl and sulphoxide metabolites, and also some inactive metabolites. About 10% of a dose is excreted in the urine as active drug or metabolites and about 4% in the faeces; the remainder is excreted as inactive metabolites.

Elimination

The half-life is approximately two and a half hours in children and approximately 3 hours in adults. Clindamycin is excreted as biological active and biological inactive metabolites in faeces, urine and bile. Faecal excretion is predominant. About 10% of the drug is excreted in the urine as active drug and about 4% in the faeces; the remainder is excreted as inactive metabolites.

Characteristics in patients

Elderly:
The half-life, volume of distribution and clearance, and extent of absorption after administration of clindamycin hydrochloride are not altered by increased age.

Patients with renal impairment:
In the presence of renal impairment, elimination half-life is prolonged; however, a dosage reduction is unnecessary in the event of mild to moderate impairment of renal function.

Patients with hepatic impairment:
In patients with moderate to severe hepatic impairment the half life is prolonged, but when giving the dose every 8 hours accumulation is rarely seen. Dose reduction is normally not necessary in patients with hepatic impairment.

5.3 Preclinical safety data

In dogs, repeated high oral doses produced ulceration of the mucosa of the stomach and gall bladder. However preclinical data reveal no special hazard for humans based on studies of repeat dose toxicity, or effects on male and female fertility as well as embryofoetal and postnatal development, genotoxicity.

Carcinogenicity studies have not been conducted.

6. PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Capsule fill:

Anhydrous Lactose

Corn starch

Talc

Magnesium stearate

Capsule cap and body:

Titanium dioxide (E171)

Gelatin

Water

Sodium lauril sulfate

Printing ink:

Shellac

Propylene glycol

Black iron oxide (E172)

Potassium hydroxide

6.2 Incompatibilities

Not applicable.

6.3 Shelf life

2 years

6.4 Special precautions for storage

No special storage conditions.

Clindamycin Actavis 150 mg capsules are available in blister packs (clear PVC/Aclar film / aluminimum foil) of

Clindamycin Actavis 300 mg capsules are available in blister packs (clear PVC/Aclar film / aluminimum foil) of

12, 15, 16, 20, 24, 30, 32, 40, 100 and 104 hard capsules.

Not all pack sizes may be marketed.

6.6 Special precautions for disposal

No special requirements for disposal.

7. MARKETING AUTHORISATION HOLDER

<[To be completed nationally]>

{Name and address}

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<{fax}>

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8. MARKETING AUTHORISATION NUMBER(S)

<[To be completed nationally]>

9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

<Date of first authorisation: {DD month YYYY}>

<Date of latest renewal: {DD month YYYY}>

<[To be completed nationally]>

10. DATE OF REVISION OF THE TEXT

26 May 2016