- Approval Id
- c07d629d27686356
- Drug Approval Emc Name
- Fluoxetine 20 mg hard capsules (PL 25298/0105)
- Drug Name
- Fluoxetine 20 mg hard capsules (PL 25298/0105)
- Company Name
- Brown & Burk UK Ltd
- Company Address
- Brown & Burk UK Limited, Micro House, Bury Street, Ruislip, HA4 7TL, UK
- Company Website
- //www.bbukltd.com
- Company Telephone
- +44 (0)203 384 7188
- Company Medical Info Direct Line
- +44 (0)203 384 7188
- Company Medical Info Email
- pv@bbukltd.com
- Company Customer Care Direct Line
- +44 (0)203 384 7188
- Company Medical Info Fax
- +44 (0)208 588 5411
- Company Stock Availability
- +44 (0)203 384 7188
- Atc Code
- N06AB03
- Legal Category
- Prescription only medicine
- Authorisation Holder
- Brown & Burk UK Ltd
5, Marryat Close, Hounslow west,
Middlesex TW4 5DQ, UK
- Authorisation Number
- PL 25298/0105
- Authorisation Date
- 14/06/2012
- Instruction Authorisation Holder
- Brown & Burk UK Ltd
5, Marryat Close, Hounslow west,
Middlesex TW4 5DQ, UK
- Instruction Authorisation Number
- PL 25298/0105
- Instruction Authorisation Date
- 14/06/2012
- Instruction Composition
- Each capsule contains fluoxetine hydrochloride equivalent to 20mg of fluoxetine
For a full list of excipients, see section 6.1.
- Instruction Dosage Form
- Capsule, hard.
The capsules are green and off-white, printed 'FLX' and 'MIL'
- Instruction Clinical Particulars
- 4.1 Therapeutic indications
\*Adults:\*
\*Major depressive episodes\*: Fluoxetine is indicated for the treatment of the symptoms of depressive illness, with or without associated anxiety symptoms, especially where sedation is not required.
\*Obsessive-compulsive disorder\*.
\*Bulimia nervosa\*: Fluoxetine is indicated as a complement of psychotherapy for the reduction of binge-eating and purging activity\*\*.\*\*
\*Children and adolescents aged 8 years and above:\*
Moderate to severe major depressive episode if depression is unresponsive to psychological therapy after 4–6 sessions. Antidepressant medication should be offered to a child or young person with moderate to severe depression only in combination with a concurrent psychological therapy.4.2 Posology and method of administration
\*\*Posology\*\*
\*\*Adults\*\*
\*Major depressive episodes\*
Adults and the elderly: The recommended dose is 20 mg daily. Dosage should be reviewed and adjusted if necessary within 3 to 4 weeks of initiation of therapy and thereafter as judged clinically appropriate. Although there may be an increased potential for undesirable effects at higher doses, in some patients, with insufficient response to 20 mg, the dose may be increased gradually up to a maximum of 60 mg (see section 5.1). Dosage adjustments should be made carefully on an individual patient basis, to maintain the patients at the lowest effective dose.
Patients with depression should be treated for a sufficient period of at least 6 months to ensure that they are free from symptoms.
\*Obsessive-compulsive disorder\*
Adults and the elderly: 20 mg/day to 60 mg/day. A dose of 20 mg/day is recommended as the initial dose. Although there may be an increased potential for side-effects at higher doses in some patients, if after 2 weeks there is insufficient response to 20 mg, the dose may be increased gradually up to a maximum of 60 mg.
If no improvement is observed within 10 weeks, treatment with fluoxetine should be reconsidered. If a good therapeutic response has been obtained, treatment can be continued at a dosage adjusted on an individual basis. While there are no systematic studies to answer the question of how long to continue fluoxetine treatment, OCD is a chronic condition and it is reasonable to consider continuation beyond 10 weeks in responding patients. Dosage adjustments should be made carefully, on an individual patient basis, to maintain the patient at the lowest effective dose. The need for treatment should be reassessed periodically. Some clinicians advocate concomitant behavioural psychotherapy for patients who have done well on pharmacotherapy.
Long-term efficacy (more than 24 weeks) has not been demonstrated in OCD.
\*Bulimia nervosa:\* Adults and the elderly: A dose of 60mg/day is recommended. Long-term efficacy (more than 3 months) has not been demonstrated in bulimia nervosa.
\*Adults- All indications:\* The recommended dose may be increased or decreased. Doses above 80mg/day have not been systematically evaluated.
\*Paediatric population - Children and adolescents aged 8 and above (Moderate to severe major depressive episode):\* Treatment should be initiated and monitored under specialist supervision. The starting dose is 10 mg. Dose adjustments should be made carefully, on an individual basis, to maintain the patient at the lowest effective dose.
After one to two weeks, the dose may be increased to 20 mg/day. Clinical trial experience with daily doses greater than 20 mg is minimal. There is only limited data on treatment beyond 9 weeks.
\*Lower weight children\*: Due to higher plasma levels in lower weight children, the therapeutic effect may be achieved with lower doses (see Section 5.2).
For paediatric patients who respond to treatment, the need for continued treatment after 6 months should be reviewed. If no clinical benefit is achieved within 9 weeks, treatment should be reconsidered.
\*Elderly:\* Caution is recommended when increasing the dose and the daily dose should generally not exceed 40mg. Maximum recommended dose is 60mg/day.
\*Hepatic impairment:\* A lower or less frequent dose (e.g., 20mg every second day) should be considered in patients with hepatic impairment (see section 5.2), or in patients where concomitant medication has the potential for interaction with Fluoxetine (see section 4.5).
\*Withdrawal symptoms seen on discontinuation of fluoxetine:\* Abrupt discontinuation should be avoided. When stopping treatment with fluoxetine the dose should be gradually reduced over a period of at least one to two weeks in order to reduce the risk of withdrawal reactions (see section 4.4 and section 4.8). If intolerable symptoms occur following a decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the physician may continue decreasing the dose, but at a more gradual rate.
\*\*Method of administration\*\*
For oral administration.
Fluoxetine may be administered as a single or divided dose, during or between meals.
When dosing is stopped, active drug substances will persist in the body for weeks. This should be borne in mind when starting or stopping treatment.4.3 Contraindications
Hypersensitivity to fluoxetine or to any of the excipients listed in section 6.1.
Fluoxetine is contra-indicated in combination with irreversible, non-selective monoamine oxidase inhibitors (e.g. iproniazid) (see sections 4.4 and 4.5).
Fluoxetine is contra-indicated in combination with metoprolol used in cardiac failure (see section 4.5).4.4 Special warnings and precautions for use
\*Paediatric population - Use in children and adolescents under 18 years of age:\*
Suicide-related behaviours (suicide attempt and suicidal thoughts), and hostility (predominantly aggression, oppositional behaviour and anger) were more frequently observed in clinical trials among children and adolescents treated with antidepressants compared to those treated with placebo. Fluoxetine should only be used in children and adolescents aged 8 to 18 years for the treatment of moderate to severe major depressive episodes and it should not be used in other indications. If, based on clinical need, a decision to treat is nevertheless taken, the patient should be carefully monitored for the appearance of suicidal symptoms. In addition, only limited evidence is available concerning long-term effect on safety in children and adolescents, including effects on growth, sexual maturation and cognitive, emotional and behavioural developments (see section 5.3).
In a 19-week clinical trial decreased height and weight gain was observed in children and adolescents treated with fluoxetine (see section 5.1). It has not been established whether there is an effect on achieving normal adult height. The possibility of a delay in puberty cannot be ruled out (see sections 5.3 and 4.8). Growth and pubertal development (height, weight and TANNER staging) should therefore be monitored during and after treatment with fluoxetine. If either is slowed, referral to a paediatrician should be considered.
In paediatric trials, mania and hypomania were commonly reported (see section 4.8). Therefore, regular monitoring for the occurrence of mania/hypomania is recommended. Fluoxetine should be discontinued in any patient entering a manic phase.
It is important that the prescribers discuss carefully the risks and benefits of treatment with the child / young person and / or their parents.
\*Rash and allergic reactions\*: Rash, anaphylactoid events, angioneurotic oedema, urticaria and progressive systemic events, sometimes serious (involving skin, kidney, liver, or lung), have been reported. Upon the appearance of rash or of other allergic phenomena for which an alternative aetiology cannot be identified, fluoxetine should be discontinued.
\*Seizures:\* Seizures are a potential risk with antidepressant drugs. Therefore, as with other antidepressants, fluoxetine should be introduced cautiously in patients who have a history of seizures. Treatment should be discontinued in any patient who develops seizures or where there is an increase in seizure frequency. Fluoxetine should be avoided in patients with unstable seizure disorders/epilepsy, and patients with controlled epilepsy should be carefully monitored (see section 4.5).
\*Mania:\* Antidepressants should be used with caution in patients with a history of mania/hypomania. As with all antidepressants, fluoxetine should be discontinued in any patient entering a manic phase.
\*Hepatic/renal function:\* Fluoxetine is extensively metabolised by the liver and excreted by the kidneys. A lower dose, e.g., alternate day dosing, is recommended in patients with significant hepatic dysfunction. When given fluoxetine 20mg/day for 2 months, patients with severe renal failure (GFR <10ml/min) requiring dialysis showed no difference in plasma levels of fluoxetine or norfluoxetine compared to controls with normal renal function.
\*Tamoxifen:\* Fluoxetine, a potent inhibitor of CYP2D6, may lead to reduced concentrations of endoxifen, one of the most important active metabolites of tamoxifen. Therefore, fluoxetine should whenever possible be avoided during tamoxifen treatment (see section 4.5).
\*Cardiovascular Effects\*
Cases of QT interval prolongation and ventricular arrhythmia including torsade de pointes have been reported during the post-marketing period (see sections 4.5, 4.8 and 4.9).
Fluoxetine should be used with caution in patients with conditions such as congenital long QT syndrome, a family history of QT prolongation or other clinical conditions that predispose to arrhythmias (e.g., hypokalemia and hypomagnesemia, bradycardia, acute myocardial infarction or uncompensated heart failure) or increased exposure to fluoxetine (e.g., hepatic impairment), or concomitant use with medicinal products known to induce QT prolongation and/or torsade de pointes (see section 4.5).
If patients with stable cardiac disease are treated, an ECG review should be considered before treatment is started.
If signs of cardiac arrhythmia occur during treatment with fluoxetine, the treatment should be withdrawn and an ECG should be performed.
\*Weight loss:\* Weight loss may occur in patients taking fluoxetine but it is usually proportional to baseline body weight. Only rarely have depressed or bulimic patients been discontinued for weight loss when treated with fluoxetine.
\*Diabetes:\* In patients with diabetes, treatment with an SSRI may alter glycaemic control. Hypoglycaemia has occurred during therapy with fluoxetine, and hyperglycaemia has developed following discontinuation. Insulin and/or oral hypoglycaemic dosage may need to be adjusted.
\*Suicide / suicidal thoughts or clinical worsening:\* Depression is associated with an increased risk of suicidal thoughts, self harm and suicide (suicide-related events). This risk persists until significant remission occurs. As improvement may not occur during the first few weeks or more of treatment, patients should be closely monitored until such improvement occurs. It is general clinical experience that the risk of suicide may increase in the early stages of recovery.
Other psychiatric conditions for which fluoxetine is prescribed can also be associated with an increased risk of suicide-related events. In addition, these conditions may be co-morbid with major depressive disorder. The same precautions observed when treating patients with major depressive disorder should therefore be observed when treating patients with other psychiatric disorders.
Patients with a history of suicide-related events, or those exhibiting a significant degree of suicidal ideation prior to commencement of treatment are known to be at a greater risk of suicidal thoughts or suicide attempts, and should receive careful monitoring during treatment. A meta-analysis of placebo-controlled clinical trials of antidepressant drugs in adult patients with psychiatric disorders showed an increased risk of suicidal behaviour with antidepressants compared to placebo in patients less than 25 years old.
Close supervision of patients and in particular those at high risk should accompany drug therapy especially in early treatment and following dose changes.
Patients (and caregivers of patients) should be alerted about the need to monitor for any clinical worsening, suicidal behaviour or thoughts and unusual changes in behaviour and to seek medical advice immediately if these symptoms present.
\*Akathisia / psychomotor restlessness:\* The use of fluoxetine has been associated with the development of akathisia, characterised by a subjectively unpleasant or distressing restlessness and need to move often accompanied by an inability to sit or stand still. This is most likely to occur within the first few weeks of treatment. In patients who develop these symptoms, increasing the dose may be detrimental.
\*Withdrawal symptoms seen on discontinuation of SSRI treatment:\* Withdrawal symptoms when treatment is discontinued are common, particularly if discontinuation is abrupt (see section 4.8). In clinical trials adverse events seen on treatment discontinuation occurred in approximately 60 % of patients in both fluoxetine and placebo groups. Of these adverse events, 17 % in the fluoxetine group and 12 % in the placebo group were severe in nature.
The risk of withdrawal symptoms may be dependent on several factors including the duration and dose of therapy and the rate of dose reduction. Dizziness, sensory disturbances (including paraesthesia), sleep disturbances (including insomnia and intense dreams), asthenia, agitation or anxiety, nausea and / or vomiting, tremor and headache are the most commonly reported reactions. Generally these symptoms are mild to moderate, however, in some patients they may be severe in intensity. They usually occur within the first few days of discontinuing treatment. Generally these symptoms are self-limiting and usually resolve within 2 weeks, though in some individuals they may be prolonged (2-3 months or more). It is therefore advised that fluoxetine should be gradually tapered when discontinuing treatment over a period of at least one to two weeks, according to the patient's needs (see “Withdrawal Symptoms Seen on Discontinuation of Fluoxetine, section 4.2).
\*Haemorrhage:\* There have been reports of cutaneous bleeding abnormalities, such as ecchymosis and purpura, with SSRIs. Ecchymosis has been reported as an infrequent event during treatment with fluoxetine. Other haemorrhagic manifestations (e.g., gynaecological haemorrhages, gastro-intestinal bleedings, and other cutaneous or mucous bleedings) have been reported rarely. Caution is advised in patients taking SSRIs, particularly in concomitant use with oral anticoagulants, drugs known to affect platelet function (e.g., atypical antipsychotics, such as clozapine, phenothiazines, most TCAs, aspirin, NSAIDs), or other drugs that may increase risk of bleeding, as well as in patients with a history of bleeding disorders (see section 4.5).
SSRIs/SNRIs may increase the risk of postpartum haemorrhage (see sections 4.6, 4.8)
\*Mydriasis:\* Mydriasis has been reported in association with fluoxetine; therefore, caution should be used when prescribing fluoxetine in patients with raised intraocular pressure or those at risk of acute narrow angle glaucoma.
\*Electroconvulsive therapy (ECT):\* There have been rare reports of prolonged seizures in patients on fluoxetine receiving ECT treatment, therefore caution is advisable.
\*Serotonin syndrome or neuroleptic malignant syndrome like events:\* On rare occasions, development of a serotonin syndrome or neuroleptic malignant syndrome-like events have been reported in association with treatment of fluoxetine, particularly when given in combination with other serotonergic (among others, L-tryptophan) and/or neuroleptic drugs (see section 4.5). As these syndromes may result in potentially life-threatening conditions, treatment with fluoxetine should be discontinued if such events (characterised by clusters of symptoms, such as hyperthermia, rigidity, myoclonus, autonomic instability with possible rapid fluctuations of vital signs, mental status changes, including confusion, irritability, extreme agitation, progressing to delirium and coma) occur, and supportive symptomatic treatment should be initiated.
Concomitant administration of buprenorphine/opioids and other serotonergic agents, such as MAO inhibitors, selective serotonin re-uptake inhibitors (SSRIs), serotonin norepinephrine re-uptake inhibitors (SNRIs) or tricyclic antidepressants may result in serotonin syndrome, a potentially life-threatening condition (see section 4.5).
If concomitant treatment with buprenorphine/opioids and other serotonergic agents is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose increases.
Symptoms of serotonin syndrome may include mental-status changes, autonomic instability, neuromuscular abnormalities, and/or gastrointestinal symptoms.
If serotonin syndrome is suspected, a dose reduction or discontinuation of therapy should be considered depending on the severity of the symptoms.
\*Sexual dysfunction:\*
Selective serotonin reuptake inhibitors (SSRIs)/serotonin norepinephrine reuptake inhibitors (SNRIs) may cause symptoms of sexual dysfunction (see section 4.8). There have been reports of long-lasting sexual dysfunction where the symptoms have continued despite discontinuation of SSRIs/SNRI.4.5 Interaction with other medicinal products and other forms of interaction
\*\*Paediatric population\*\*
Interaction studies have only been performed in adults.
\*Half-life:\* The long elimination half-lives of both fluoxetine and norfluoxetine should be borne in mind (see section 5.2) when considering pharmacodynamic or pharmacokinetic drug interactions (e.g., when switching from fluoxetine to other antidepressants).
\*\*Contra-indicated combinations\*\*
Irreversible, non-selective monoamine oxidase inhibitors (e.g. iproniazid): Some cases of serious and sometimes fatal reactions have been reported in patients receiving an SSRI in combination with an irreversible, non-selective monoamine oxidase inhibitor (MAOI).
These cases presented with features resembling serotonin syndrome (which may be confounded with [or diagnosed as] neuroleptic malignant syndrome). Cyproheptadine or dantrolene may benefit patients experiencing such reactions. Symptoms of a drug interaction with a MAOI include: hyperthermia, rigidity, myoclonus, autonomic instability with possible rapid fluctuations of vital signs, mental status changes that include confusion, irritability and extreme agitation progressing to delirium and coma.
Therefore, fluoxetine is contra-indicated in combination with an irreversible, non-selective MAOI (see section 4.3). Because of the two weeks-lasting effect of the latter, treatment of fluoxetine should only be started 2 weeks after discontinuation of an irreversible, non-selective MAOI. Similarly, at least 5 weeks should elapse after discontinuing fluoxetine treatment before starting an irreversible, non-selective MAOI.
Metoprolol used in cardiac failure: risk of metoprolol adverse events, including excessive bradycardia, may be increased because of an inhibition of its metabolism by fluoxetine (see section 4.3).
\*\*Not recommended combinations\*\*
Tamoxifen: Pharmacokinetic interaction between CYP2D6 inhibitors and tamoxifen, showing a 65-75 % reduction in plasma levels of one of the more active forms of the tamoxifen, i.e. endoxifen, has been reported in the literature. Reduced efficacy of tamoxifen has been reported with concomitant usage of some SSRI antidepressants in some studies. As a reduced effect of tamoxifen cannot be excluded, co-administration with potent CYP2D6 inhibitors (including fluoxetine) should whenever possible be avoided (see section 4.4).
Alcohol: In formal testing, fluoxetine did not raise blood alcohol levels or enhance the effects of alcohol. However, the combination of SSRI treatment and alcohol is not advisable.
MAOI-A including linezolid and methylthioninium chloride (methylene blue): Risk of serotonin syndrome including diarrhoea, tachycardia, sweating, tremor, confusion or coma. If the concomitant use of these active substances with fluoxetine cannot be avoided, close clinical monitoring should be undertaken and the concomitant agents should be initiated at the lower recommended doses (see section 4.4).
Mequitazine: risk of mequitazine adverse events (such as QT prolongation) may be increased because of an inhibition of its metabolism by fluoxetine.
\*\*Combinations requiring caution\*\*
Fluoxetine should be used cautiously when co-administered with:
Buprenorphine/opioids, as the risk of serotonin syndrome, a potentially life-threatening condition, is increased (see section 4.4).
Phenytoin: Changes in blood levels have been observed when combined with fluoxetine. In some cases manifestations of toxicity have occurred. Consideration should be given to using conservative titration schedules of the concomitant drug and to monitoring clinical status.
Serotoninergic drugs (lithium, tramadol, triptans, tryptophan, selegiline (MAOI-B), St. John's Wort (Hypericum perforatum)): There have been reports of mild serotonin syndrome when SSRIs were given with drugs also having a serotoninergic effect. Therefore, the concomitant use of fluoxetine with these drugs should be undertaken with caution, with closer and more frequent clinical monitoring (see section 4.4).
QT interval prolongation: Pharmacokinetic and pharmacodynamic studies between fluoxetine and other medicinal products that prolong the QT interval have not been performed. An additive effect of fluoxetine and these medicinal products cannot be excluded. Therefore, co-administration of fluoxetine with medicinal products that prolong the QT interval, such as Class IA and III antiarrhythmics, antipsychotics (e.g. phenothiazine derivatives, pimozide, haloperidol), tricyclic antidepressants, certain antimicrobial agents (e.g. sparfloxacin, moxifloxacin, erythromycin IV (intravenous), pentamidine), anti-malaria treatment particularly halofantrine, certain antihistamines (astemizole, mizolastine), should be used with caution (see sections 4.4, 4.8 and 4.9).
Drugs affecting haemostasis (oral anticoagulants, whatever their mechanism, platelets antiaggregants including aspirin and non-steroidal anti-inflammatory drugs ( NSAIDs)): risk of increased bleeding. Clinical monitoring, and more frequent monitoring of INR with oral anticoagulants, should be made. A dose adjustment during the fluoxetine treatment and after its discontinuation may be suitable (see sections 4.4 and 4.8).
Cyproheptadine: There are individual case reports of reduced antidepressant activity of fluoxetine when used in combination with cyproheptadine.
Drugs inducing hyponatremia: Hyponatremia is an undesirable effect of fluoxetine. Use in combination with other agents associated with hyponatremia (e.g. diuretics, desmopressin, carbamazepine and oxcarbazepine) may lead to an increased risk (see section 4.8).
Drugs lowering the epileptogenic threshold: Seizures are an undesirable effect of fluoxetine. Use in combination with other agents which may lower the seizure threshold (for example, tricyclic antidepressants (TCAs), other SSRIs, phenothiazines, butyrophenones, mefloquine, chloroquine, bupropion, tramadol) may lead to an increased risk.
Other drugs metabolised by CYP2D6 isoenzyme: Fluoxetine is a strong inhibitor of CYP2D6 enzyme, therefore concomitant therapy with drugs also metabolised by this enzyme system may lead to drug interactions, notably those having a narrow therapeutic index (such as flecainide, encainide, vinblastine, propafenone and nebivolol) and those that are titrated, but also with atomoxetine, carbamazepine, tricyclic antidepressants and risperidone. They should be initiated at or adjusted to the low end of their dose range. This may also apply if fluoxetine has been taken in the previous 5 weeks.
Greater than two-fold increases of previously stable plasma levels of TCAs have been observed when administered in combination with Fluoxetine.4.6 Fertility, pregnancy and lactation
\*Pregnanc\*y: Fluoxetine should not be used during pregnancy unless the clinical condition of the woman requires treatment with fluoxetine and justifies the potential risk to the foetus. Abrupt discontinuation of therapy should be avoided during pregnancy (see section 4.2 "Posology and method of administration"). Furthermore, although fluoxetine can be used during pregnancy, but caution should be exercised when prescribing to pregnant women, especially during late pregnancy or just prior to the onset of labour, since the following effects have been reported in neonates: irritability, tremor, hypotonia, persistent crying, difficulty in sucking or in sleeping. These symptoms may indicate either serotonergic effects or a withdrawal syndrome. The time to occur and the duration of these symptoms may be related to the long half-life of fluoxetine (4-6 days) and its active metabolite, norfluoxetine (4-16 days).
Epidemiological data have suggested that the use of SSRIs in pregnancy, particular in late pregnancy, may increase the risk of persistent pulmonary hypertension in the newborn(PPHN). The observed risk was approximately 5 cases per 1000 pregnancies. In the general population 1 to 2 cases of PPHN per 1000 pregnancies occur.
Some epidemiological studies suggest an increased risk of cardiovascular defects associated with the use of fluoxetine during the first trimester. The mechanism is unknown. Overall the data suggest that the risk having an infant with a cardiovascular defect following maternal fluoxetine exposure is in the region of 2/100 compared with an expected rate for such defects of approximately 1/100 in the general population.
Observational data indicate an increased risk (less than 2-fold) of postpartum haemorrhage following SSRI/SNRI exposure within the month prior to birth (see sections 4.4, 4.8).
\*Breast-feeding:\* Fluoxetine and its metabolite, norfluoxetine, are known to be excreted in human breast milk. Adverse events have been reported in breast-feeding infants. If treatment with fluoxetine is considered necessary, discontinuation of breast-feeding should be considered; however, if breast-feeding is continued, the lowest effective dose of fluoxetine should be prescribed.
\*Fertility:\* Animal data have shown that fluoxetine may affect sperm quality (see section 5.3).
Human case reports with some SSRIs have shown that an effect on sperm quality is reversible.
Impact on human fertility has not been observed so far.4.7 Effects on ability to drive and use machines
Fluoxetine has no or negligible influence on the ability to drive and use machine. Although fluoxetine has been shown not to affect psychomotor performance in healthy volunteers, any psychoactive drug may impair judgement or skills. Patients should be advised to avoid driving a car or operating hazardous machinery until they are reasonably certain that their performance is not affected.4.8 Undesirable effects
\*a. Summary of the safety profile:\*
The most commonly reported adverse reactions in patients treated with fluoxetine were headache, nausea, insomnia, fatigue and diarrhoea.
Undesirable effects may decrease in intensity and frequency with continued treatment and do not generally lead to cessation of therapy.
\*b. Tabulated list of adverse reactions:\*
The table below gives the adverse reactions observed with fluoxetine treatment in adult and paediatric populations. Some of these adverse reactions are in common with other SSRIs.
The following frequencies have been calculated from clinical trials in adults (n = 9297) and from spontaneous reporting.
Frequency estimate: Very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1,000 to <1/100), rare (≥1/10,000), very rare (<1/10,000); not known (frequency cannot be estimated from the available data).
| | | | | | |
| --- | --- | --- | --- | --- | --- |
| Very Common | Common | Uncommon | Rare | Very rare | Not known |
| \*Blood and lymphatic system disorders\* | | | | | |
| | | | Thrombocytopenia Neutropenia Leucopenia | | |
| \*Immune system disorders\* | | | | | |
| | | | Anaphylactic reaction | | |
| | | | Serum sickness | | |
| \*Endocrine disorders\* | | | | | |
| | | | Inappropriate antidiuretic hormone secretion | | |
| \*Metabolism and nutrition disorders\* | | | | | |
| | Decreased appetite1 | | Hyponatraemia | | |
| \*Psychiatric disorders\* | | | | | |
| Insomnia2 | Anxiety Nervousness Restlessness Tension Libido decreased3 Sleep disorder Abnormal dreams4 | Depersonalisation Elevated mood Euphoric mood Thinking abnormal Orgasm abnormal5 Bruxism Suicidal thoughts and behaviour 6 | Hypomania Mania Hallucinations Agitation Panic attacks Confusion Dysphemia Aggression | | |
| \*Nervous system disorders\* | | | | | |
| Headache | Disturbance in attention Dizziness Dysgeusia Lethargy Somnolence7 Tremor | Psychomotor hyperactivity Dyskinesia Ataxia Balance disorder Myoclonus Memory impairment | Convulsion Akathisia Buccoglossal syndrome Serotonin syndrome | | |
| \*Eye disorders\* | | | | | |
| | Vision blurred | Mydriasis | | | |
| \*Ear and labyrinth disorders\* | | | | | |
| | | Tinnitus | | | |
| \*Cardiac disorders\* | | | | | |
| | Palpitations Electrocardiogram QT prolonged (QTcF ≥450 msec)8 | | Ventricular arrhythmia including torsade de pointes | | |
| \*Vascular disorders\* | | | | | |
| | Flushing9 | Hypotension | Vasculitis Vasodilatation | | |
| \*Respiratory, thoracic and mediastinal disorders\* | | | | | |
| | Yawning | Dyspnoea Epistaxis | Pharyngitis Pulmonary events (inflammatory processes of varying histopathology and/or fibrosis) 10 | | |
| \*Gastrointestinal disorders\* | | | | | |
| Diarrhoea Nausea | Vomiting Dyspepsia Dry mouth | Dysphagia Gastrointestinal haemorrhage11 | Oesophageal pain | | |
| \*Hepato-biliary disorders\* | | | | | |
| | | | Idiosyncratic hepatitis | | |
| \*Skin and subcutaneous tissue disorders\* | | | | | |
| | Rash12 Urticaria Pruritus Hyperhidrosis | Alopecia Increased tendency to bruise Cold sweat | Angioedema Ecchymosis Photosensitivity reaction Purpura Erythema multiforme Stevens-Johnson syndrome Toxic Epidermal Necrolysis (Lyell Syndrome) | | |
| \*Musculoskeletal and connective tissue disorders\* | | | | | |
| | Arthralgia | Muscle twitching | Myalgia | | |
| \*Renal and urinary disorders\* | | | | | |
| | Frequent urination13 | Dysuria | Urinary retention Micturition disorder | | |
| \*Reproductive system and breast disorders\* | | | | | |
| | Gynaecological bleeding14 Erectile dysfunction Ejaculation disorder15 | Sexual dysfunction | Galactorrhoea Hyperprolactinemia Priapism | | postpartum haemorrhage\\* |
| \*General disorders and administration site conditions\* | | | | | |
| Fatigue16 | Feeling jittery Chills | Malaise Feeling abnormal Feeling cold Feeling hot | Mucosal haemorrhage | | |
| \*Investigations\* | | | | | |
| | Weight decreased | Transaminases increased Gamma-glutamyltransferase increased | | | |
1 Includes anorexia
2 Includes early morning awakening, initial insomnia, middle insomnia
3 Includes loss of libido
4 Includes nightmares
5 Includes anorgasmia
6 Includes completed suicide, depression suicidal, intentional self-injury, self-injurious ideation, suicidal behaviour, suicidal ideation, suicide attempt, morbid thoughts, self-injurious behaviour. These symptoms may be due to underlying disease
7 Includes hypersomnia, sedation
8 Based on ECG measurements from clinical trials
9 Includes hot flush
10 Includes atelectasis, interstitial lung disease, pneumonitis
11 Includes most frequently gingival bleeding, haematemesis, haematochezia, rectal haemorrhage, diarrhea, haemorrhagic, melaena, and gastric ulcerhaemorrhage
12 Includes erythema, exfoliative rash, heat rash, rash, rash erythematous, rash follicular, rash generalized, rash macular, rash macular-papular, rash morbilliform, rash papular, rash pruritic, rash vesicular, umbilical erythema rash
13 Includes pollakiuria
14 Includes cervix haemorrhage, uterine dysfunction, uterine bleeding, genital haemorrhage, menometrorhagia, menorrhagia, metrorrhagia, polymenorrhea, postmenopausal haemorrhage, uterine haemorrhage, vaginal haemorrhage
15 Includes ejaculation failure, ejaculation dysfunction, premature ejaculation, ejaculation delayed, retrograde ejaculation
16 Includes asthenia
\\* This event has been reported for the therapeutic class of SSRIs/SNRIs (see sections 4.4, 4.6).
\*\*\*\*Description of selected adverse reactions\*\*\*\*
\*Suicide/suicidal thoughts or clinical worsening\*: Cases of suicidal ideation and suicidal behaviour have been reported during fluoxetine therapy or early after treatment discontinuation (see section 4.4).
\*Bone fractures:\* Epidemiological studies, mainly conducted in patients 50 years of age and older, show an increased risk of bone fractures in patients receiving SSRIs and TCAs. The mechanism leading to this risk is unknown.
\*\*\*\*Withdrawal symptoms seen on discontinuation of SSRI treatment\*\*\*\*
Discontinuation of fluoxetine (particularly when abrupt) commonly leads to withdrawal symptoms. Dizziness, sensory disturbances (including paraesthesia), sleep disturbances (including insomnia and intense dreams), asthenia, agitation or anxiety, nausea and/or vomiting, tremor and headache are the most commonly reported reactions. Generally these events are mild to moderate and are self-limiting, however, in some patients they may be severe and/or prolonged (see section 4.4). It is therefore advised that when fluoxetine treatment is no longer required, gradual discontinuation by dose tapering should be carried out (see section 4.2 and 4.4).
\*\*\*\*Paediatric population (see sections 4.4 and 5.1)\*\*\*\*
Adverse reactions that have been observed specifically or with a different frequency in this population are described below. Frequencies for these events are based on paediatric clinical trial exposures (n = 610).
In paediatric clinical trials, suicide-related behaviours (suicide attempt and suicidal thoughts), hostility (the events reported were: anger, irritability, aggression, agitation, activation syndrome), manic reactions, including mania and hypomania (no prior episodes reported in these patients) and epistaxis, were commonly reported and were more frequently observed among children and adolescents treated with antidepressants compared to those treated with placebo.
Isolated cases of growth retardation have been reported from clinical use (See also section 5.1).
In paediatric clinical trials, fluoxetine treatment was also associated with a decrease in alkaline phosphatase levels.
Isolated cases of adverse events potentially indicating delayed sexual maturation or sexual dysfunction have been reported from paediatric clinical use (See also section 5.3).
\*\*\*\*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 www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.4.9 Overdose
\*Symptoms\*
Cases of overdose of fluoxetine alone usually have a mild course. Symptoms of overdose have included nausea, vomiting, agitation, tremor, nystagmus, drowsiness seizures, cardiovascular dysfunction ranging from asymptomatic arrhythmias (including nodal rhythm and ventricular arrhythmias) or ECG changes indicative of QTc prolongationto cardiac arrest (including very rare cases of Torsade de Pointes), pulmonary dysfunction, and signs of altered CNS status ranging from excitation to coma. Fatality attributed to overdose of fluoxetine alone has been extremely rare.
\*Management\*
Cardiac and vital signs monitoring are recommended, along with general symptomatic and supportive measures. No specific antidote is known.
Forced diuresis, dialysis, haemoperfusion, and exchange transfusion are unlikely to be of benefit. Activated charcoal, which may be used with sorbitol, may be as or more effective than emesis or lavage. In managing overdosage, consider the possibility of multiple drug involvement. An extended time for close medical observation may be needed in patients who have taken excessive quantities of a tricyclic antidepressant if they are also taking, or have recently taken, fluoxetine.
- Instruction Pharmacology
- 5.1 Pharmacodynamic properties
Pharmacotherapeutic group: selective serotonin reuptake inhibitors (SSRI) ATC code: N06AB03
\*\*Mechanism of action\*\*
Fluoxetine is a selective inhibitor of serotonin reuptake, and this probably accounts for the mechanism of action. Fluoxetine has practically no affinity to other receptors such as α1-, α2-, and β-adrenergic; serotonergic; dopaminergic; histaminergic1; muscarinic; and GABA receptors.
\*\*Clinical efficacy and safety\*\*
\*Major depressive episodes:\* Clinical trials in patients with major depressive episodes have been conducted versus placebo and active controls. Fluoxetine has been shown to be significantly more effective than placebo, as measured by the Hamilton Depression Rating Scale (HAM-D). In these studies, Fluoxetine produced a significantly higher rate of response (defined by a 50% decrease in the HAM-D score) and remission, compared to placebo.
\*Dose response:\* In the fixed dose studies of patients with major depression there is a flat dose response curve, providing no suggestion of advantage in terms of efficacy for using higher than the recommended doses. However, it is clinical experience that up titrating might be beneficial for some patients.
\*Obsessive-compulsive disorder:\* In short-term trials (under 24 weeks), fluoxetine was shown to be significantly more effective than placebo. There was a therapeutic effect at 20mg/day, but higher doses (40 or 60mg/day) showed a higher response rate. In long-term studies (three short-term studies extension phase and a relapse prevention study) efficacy has not been shown.
\*Bulimia nervosa:\* In short-term trials (under 16 weeks), in out-patients fulfilling DSM-III-R-criteria for bulimia nervosa, fluoxetine 60mg/day was shown to be significantly more effective than placebo for the reduction of bingeing and purging activities. However, for long-term efficacy no conclusion can be drawn.
\*Pre-Menstrual Dysphoric Disorder\*:Two placebo-controlled studies were conducted in patients meeting Pre-Menstrual Dysphoric Disorder (PMDD) diagnostic criteria according to DSM-IV. Patients were included if they had symptoms of sufficient severity to impair social and occupational function and relationships with others. Patients using oral contraceptives were excluded. In the first study of continuous 20mg daily dosing for 6 cycles, improvement was observed in the primary efficacy parameter (irritability, anxiety, and dysphoria). In the second study, with intermittent luteal phase dosing (20mg daily for 14 days) for 3 cycles, improvement was observed in the primary efficacy parameter (Daily Record of Severity of Problems score). However, definitive conclusions on efficacy and duration of treatment cannot be drawn from these studies.
\*\*Paediatric population\*\*
\*Major depressive episodes (children and adolescents):\* Clinical trials in children and adolescents aged 8 years and above have been conducted versus placebo. Fluoxetine, at a dose of 20mg, has been shown to be significantly more effective than placebo in two short-term pivotal studies, as measured by the reduction of Childhood Depression Rating Scale-Revised (CDRS-R) total scores and Clinical Global Impression of Improvement (CGI-I) scores. In both studies, patients met criteria for moderate to severe MDD (DSM-III or DSM-IV) at three different evaluations by practising child psychiatrists. Efficacy in the fluoxetine trials may depend on the inclusion of a selective patient population (one that has not spontaneously recovered within a period of 3-5 weeks and whose depression persisted in the face of considerable attention). There is only limited data on safety and efficacy beyond 9 weeks. In general, efficacy of fluoxetine was modest. Response rates (the primary endpoint, defined as a 30% decrease in the CDRS-R score) demonstrated a statistically significant difference in one of the two pivotal studies (58% for fluoxetine versus 32% for placebo, \*P\* = 0.013; and 65% for fluoxetine versus 54% for placebo, \*P\* = 0.093). In these two studies, the mean absolute changes in CDRS-R from baseline to endpoint were 20 for fluoxetine versus 11 for placebo, \*P\* = 0.002; and 22 for fluoxetine versus 15 for placebo, \*P\* <0.001.
\*Effects on growth, see sections 4.4 and 4.8:\* After 19 weeks of treatment, paediatric subjects treated with fluoxetine in a clinical trial gained an average of 1.1 cm less in height (p=0.004) and 1.1 kg less in weight (p=0.008) than subjects treated with placebo.
In a retrospective matched control observational study with a mean of 1.8 years of exposure to fluoxetine, paediatric subjects treated with fluoxetine had no difference in growth adjusted for expected growth in height from their matched, untreated controls (0.0 cm, p=0.9673).5.2 Pharmacokinetic properties
\*Absorption:\* Fluoxetine is well absorbed from the gastro-intestinal tract after oral administration. The bioavailability is not affected by food intake.
\*Distribution:\* Fluoxetine is extensively bound to plasma proteins (about 95%) and it is widely distributed (volume of distribution: 20-40 l/kg). Steady-state plasma concentrations are achieved after dosing for several weeks. Steady-state concentrations after prolonged dosing are similar to concentrations seen at 4 to 5 weeks. When dosing is stopped, active drug substances will persist in the body for weeks. This should be borne in mind when starting or stopping treatment. Plasma concentrations do not appear to increase without limit because, in addition to metabolism by the hepatic cytochrome P450IID6 isoenzyme system, there are non-saturable pathways. Patients receiving fluoxetine for as long as 3 years exhibited average plasma concentrations, similar to those seen among patients treated for 4 or 5 weeks.
\*Biotransformation:\* Fluoxetine has a non-linear pharmacokinetic profile with first pass liver effect. Maximum plasma concentration is generally achieved 6 to 8 hours after administration. Fluoxetine is extensively metabolised by the polymorphic enzyme CYP2D6. Fluoxetine is primarily metabolised by the liver to the active metabolite norfluoxetine (desmethylfluoxetine), by desmethylation.
\*Elimination:\* Fluoxetine has a half-life of 1 to 3 days after acute administration. The half-life may be prolonged to 4 to 6 days after chronic administration. The active metabolite, norfluoxetine, has a mean half-life of 9.3 days after multiple dosing (range 4 to 16 days). These long half-lives are responsible for persistence of the drug for 5-6 weeks after discontinuation. Excretion is mainly (about 60%) via the kidney. Fluoxetine is secreted into breast milk.
\*Special populations\*
\*Elderly:\* Kinetic parameters are not altered in healthy elderly when compared to younger subjects.
\*Paediatric:\* The mean fluoxetine concentration in children is approximately 2-fold higher than that observed in adolescents and the mean norfluoxetine concentration 1.5-fold higher. Steady-state plasma concentrations are dependent on body weight and are higher in lower weight children (see section 4.2). As in adults, fluoxetine and norfluoxetine accumulated extensively following multiple oral dosing; steady-state concentrations were achieved within 3 to 4 weeks of daily dosing.
\*Hepatic impairment:\* In case of hepatic insufficiency (alcoholic cirrhosis), fluoxetine and norfluoxetine half-lives are increased to 7 and 12 days, respectively. A lower or less frequent dose should be considered.
\*Renal impairment:\* After single-dose administration of fluoxetine in patients with mild, moderate, or complete (anuria) renal insufficiency, kinetic parameters have not been altered when compared to healthy volunteers. However, after repeated administration, an increase in steady-state plateau of plasma concentrations may be observed.5.3 Preclinical safety data
There is no evidence of carcinogenicity, mutagenicity, or impairment of fertility from \*in vitro\* or animal studies.
\*Adult animal studies\*
In a 2-generation rat reproduction study, fluoxetine did not produce adverse effects on the mating or fertility of rats, was not teratogenic, and did not affect growth, development, or reproductive parameters of the offspring.
The concentrations in the diet provided doses approximately equivalent to 1.5, 3.9, and 9.7 mg fluoxetine/kg body weight.
Male mice treated daily for 3 months with fluoxetine in the diet at a dose approximately equivalent to 31 mg/kg showed a decrease in testis weight and hypospermatogenesis. However, this dose level exceeded the maximum-tolerated dose (MTD) as significant signs of toxicity were seen.
\*\*\*Juvenile animal studies\*\*\*
In a juvenile toxicology study in CD rats, administration of 30 mg/kg/day of fluoxetine hydrochloride on postnatal days 21 to 90 resulted in irreversible testicular degeneration and necrosis, epididymal epithelial vacuolation, immaturity and inactivity of the female reproductive tract and decreased fertility. Delays in sexual maturation occurred in males (10 and 30 mg/kg/day) and females (30 mg/kg/day). The significance of these findings in humans is unknown. Rats administered 30 mg/kg also had decreased femur lengths compared with controls and skeletal muscle degeneration, necrosis and regeneration. At 10 mg/kg/day, plasma levels achieved in animals were approximately 0.8 to 8.8 fold (fluoxetine) and 3.6 to 23.2 fold (norfluoxetine) those usually observed in paediatric patients. At 3 mg/kg/day, plasma levels achieved in animals were approximately 0.04 to 0.5 fold (fluoxetine) and 0.3 to 2.1 fold (norfluoxetine) those usually achieved in paediatric patients.
A study in juvenile mice has indicated that inhibition of the serotonin transporter prevents the accrual of bone formation. This finding would appear to be supported by clinical findings. The reversibility of this effect has not been established.
Another study in juvenile mice (treated on postnatal days 4 to 21) has demonstrated that inhibition of the serotonin transporter had long lasting effects on the behaviour of the mice. There is no information on whether the effect was reversible. The clinical relevance of this finding has not been established.
- Instruction Pharmaceutical Particulars
- 6.1 List of excipients
Pregelatinised maize starch
\*\*Capsule shell components\*\*
\*\*Body\*\*
Yellow iron oxide E 172
Titanium dioxide E 171
Gelatin
\*\*Cap\*\*
Brilliant blue E133
Yellow iron oxide E 172
Titanium dioxide E 171
Gelatin
\*\*Printing ink components\*\*
Activated charcoal and shellac (E904).6.2 Incompatibilities
Not applicable.6.3 Shelf life
42 Months6.4 Special precautions for storage
Do not store above 25°C.
Store in the original package in order to protect from moisture6.5 Nature and contents of container
10, 14, 20, 30, 50, 70 or 100 Capsules packed in PVC/PVdC Aluminium blister.
Not all pack sizes may be marketed.6.6 Special precautions for disposal and other handling
No special requirements
- Instruction Content
- ## Composition
Each capsule contains fluoxetine hydrochloride equivalent to 20mg of fluoxetine
For a full list of excipients, see section 6.1.
## Pharmaceutical Form
Capsule, hard.
The capsules are green and off-white, printed 'FLX' and 'MIL'
## Clinical Particulars
4.1 Therapeutic indications
\*Adults:\*
\*Major depressive episodes\*: Fluoxetine is indicated for the treatment of the symptoms of depressive illness, with or without associated anxiety symptoms, especially where sedation is not required.
\*Obsessive-compulsive disorder\*.
\*Bulimia nervosa\*: Fluoxetine is indicated as a complement of psychotherapy for the reduction of binge-eating and purging activity\*\*.\*\*
\*Children and adolescents aged 8 years and above:\*
Moderate to severe major depressive episode if depression is unresponsive to psychological therapy after 4–6 sessions. Antidepressant medication should be offered to a child or young person with moderate to severe depression only in combination with a concurrent psychological therapy.4.2 Posology and method of administration
\*\*Posology\*\*
\*\*Adults\*\*
\*Major depressive episodes\*
Adults and the elderly: The recommended dose is 20 mg daily. Dosage should be reviewed and adjusted if necessary within 3 to 4 weeks of initiation of therapy and thereafter as judged clinically appropriate. Although there may be an increased potential for undesirable effects at higher doses, in some patients, with insufficient response to 20 mg, the dose may be increased gradually up to a maximum of 60 mg (see section 5.1). Dosage adjustments should be made carefully on an individual patient basis, to maintain the patients at the lowest effective dose.
Patients with depression should be treated for a sufficient period of at least 6 months to ensure that they are free from symptoms.
\*Obsessive-compulsive disorder\*
Adults and the elderly: 20 mg/day to 60 mg/day. A dose of 20 mg/day is recommended as the initial dose. Although there may be an increased potential for side-effects at higher doses in some patients, if after 2 weeks there is insufficient response to 20 mg, the dose may be increased gradually up to a maximum of 60 mg.
If no improvement is observed within 10 weeks, treatment with fluoxetine should be reconsidered. If a good therapeutic response has been obtained, treatment can be continued at a dosage adjusted on an individual basis. While there are no systematic studies to answer the question of how long to continue fluoxetine treatment, OCD is a chronic condition and it is reasonable to consider continuation beyond 10 weeks in responding patients. Dosage adjustments should be made carefully, on an individual patient basis, to maintain the patient at the lowest effective dose. The need for treatment should be reassessed periodically. Some clinicians advocate concomitant behavioural psychotherapy for patients who have done well on pharmacotherapy.
Long-term efficacy (more than 24 weeks) has not been demonstrated in OCD.
\*Bulimia nervosa:\* Adults and the elderly: A dose of 60mg/day is recommended. Long-term efficacy (more than 3 months) has not been demonstrated in bulimia nervosa.
\*Adults- All indications:\* The recommended dose may be increased or decreased. Doses above 80mg/day have not been systematically evaluated.
\*Paediatric population - Children and adolescents aged 8 and above (Moderate to severe major depressive episode):\* Treatment should be initiated and monitored under specialist supervision. The starting dose is 10 mg. Dose adjustments should be made carefully, on an individual basis, to maintain the patient at the lowest effective dose.
After one to two weeks, the dose may be increased to 20 mg/day. Clinical trial experience with daily doses greater than 20 mg is minimal. There is only limited data on treatment beyond 9 weeks.
\*Lower weight children\*: Due to higher plasma levels in lower weight children, the therapeutic effect may be achieved with lower doses (see Section 5.2).
For paediatric patients who respond to treatment, the need for continued treatment after 6 months should be reviewed. If no clinical benefit is achieved within 9 weeks, treatment should be reconsidered.
\*Elderly:\* Caution is recommended when increasing the dose and the daily dose should generally not exceed 40mg. Maximum recommended dose is 60mg/day.
\*Hepatic impairment:\* A lower or less frequent dose (e.g., 20mg every second day) should be considered in patients with hepatic impairment (see section 5.2), or in patients where concomitant medication has the potential for interaction with Fluoxetine (see section 4.5).
\*Withdrawal symptoms seen on discontinuation of fluoxetine:\* Abrupt discontinuation should be avoided. When stopping treatment with fluoxetine the dose should be gradually reduced over a period of at least one to two weeks in order to reduce the risk of withdrawal reactions (see section 4.4 and section 4.8). If intolerable symptoms occur following a decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the physician may continue decreasing the dose, but at a more gradual rate.
\*\*Method of administration\*\*
For oral administration.
Fluoxetine may be administered as a single or divided dose, during or between meals.
When dosing is stopped, active drug substances will persist in the body for weeks. This should be borne in mind when starting or stopping treatment.4.3 Contraindications
Hypersensitivity to fluoxetine or to any of the excipients listed in section 6.1.
Fluoxetine is contra-indicated in combination with irreversible, non-selective monoamine oxidase inhibitors (e.g. iproniazid) (see sections 4.4 and 4.5).
Fluoxetine is contra-indicated in combination with metoprolol used in cardiac failure (see section 4.5).4.4 Special warnings and precautions for use
\*Paediatric population - Use in children and adolescents under 18 years of age:\*
Suicide-related behaviours (suicide attempt and suicidal thoughts), and hostility (predominantly aggression, oppositional behaviour and anger) were more frequently observed in clinical trials among children and adolescents treated with antidepressants compared to those treated with placebo. Fluoxetine should only be used in children and adolescents aged 8 to 18 years for the treatment of moderate to severe major depressive episodes and it should not be used in other indications. If, based on clinical need, a decision to treat is nevertheless taken, the patient should be carefully monitored for the appearance of suicidal symptoms. In addition, only limited evidence is available concerning long-term effect on safety in children and adolescents, including effects on growth, sexual maturation and cognitive, emotional and behavioural developments (see section 5.3).
In a 19-week clinical trial decreased height and weight gain was observed in children and adolescents treated with fluoxetine (see section 5.1). It has not been established whether there is an effect on achieving normal adult height. The possibility of a delay in puberty cannot be ruled out (see sections 5.3 and 4.8). Growth and pubertal development (height, weight and TANNER staging) should therefore be monitored during and after treatment with fluoxetine. If either is slowed, referral to a paediatrician should be considered.
In paediatric trials, mania and hypomania were commonly reported (see section 4.8). Therefore, regular monitoring for the occurrence of mania/hypomania is recommended. Fluoxetine should be discontinued in any patient entering a manic phase.
It is important that the prescribers discuss carefully the risks and benefits of treatment with the child / young person and / or their parents.
\*Rash and allergic reactions\*: Rash, anaphylactoid events, angioneurotic oedema, urticaria and progressive systemic events, sometimes serious (involving skin, kidney, liver, or lung), have been reported. Upon the appearance of rash or of other allergic phenomena for which an alternative aetiology cannot be identified, fluoxetine should be discontinued.
\*Seizures:\* Seizures are a potential risk with antidepressant drugs. Therefore, as with other antidepressants, fluoxetine should be introduced cautiously in patients who have a history of seizures. Treatment should be discontinued in any patient who develops seizures or where there is an increase in seizure frequency. Fluoxetine should be avoided in patients with unstable seizure disorders/epilepsy, and patients with controlled epilepsy should be carefully monitored (see section 4.5).
\*Mania:\* Antidepressants should be used with caution in patients with a history of mania/hypomania. As with all antidepressants, fluoxetine should be discontinued in any patient entering a manic phase.
\*Hepatic/renal function:\* Fluoxetine is extensively metabolised by the liver and excreted by the kidneys. A lower dose, e.g., alternate day dosing, is recommended in patients with significant hepatic dysfunction. When given fluoxetine 20mg/day for 2 months, patients with severe renal failure (GFR <10ml/min) requiring dialysis showed no difference in plasma levels of fluoxetine or norfluoxetine compared to controls with normal renal function.
\*Tamoxifen:\* Fluoxetine, a potent inhibitor of CYP2D6, may lead to reduced concentrations of endoxifen, one of the most important active metabolites of tamoxifen. Therefore, fluoxetine should whenever possible be avoided during tamoxifen treatment (see section 4.5).
\*Cardiovascular Effects\*
Cases of QT interval prolongation and ventricular arrhythmia including torsade de pointes have been reported during the post-marketing period (see sections 4.5, 4.8 and 4.9).
Fluoxetine should be used with caution in patients with conditions such as congenital long QT syndrome, a family history of QT prolongation or other clinical conditions that predispose to arrhythmias (e.g., hypokalemia and hypomagnesemia, bradycardia, acute myocardial infarction or uncompensated heart failure) or increased exposure to fluoxetine (e.g., hepatic impairment), or concomitant use with medicinal products known to induce QT prolongation and/or torsade de pointes (see section 4.5).
If patients with stable cardiac disease are treated, an ECG review should be considered before treatment is started.
If signs of cardiac arrhythmia occur during treatment with fluoxetine, the treatment should be withdrawn and an ECG should be performed.
\*Weight loss:\* Weight loss may occur in patients taking fluoxetine but it is usually proportional to baseline body weight. Only rarely have depressed or bulimic patients been discontinued for weight loss when treated with fluoxetine.
\*Diabetes:\* In patients with diabetes, treatment with an SSRI may alter glycaemic control. Hypoglycaemia has occurred during therapy with fluoxetine, and hyperglycaemia has developed following discontinuation. Insulin and/or oral hypoglycaemic dosage may need to be adjusted.
\*Suicide / suicidal thoughts or clinical worsening:\* Depression is associated with an increased risk of suicidal thoughts, self harm and suicide (suicide-related events). This risk persists until significant remission occurs. As improvement may not occur during the first few weeks or more of treatment, patients should be closely monitored until such improvement occurs. It is general clinical experience that the risk of suicide may increase in the early stages of recovery.
Other psychiatric conditions for which fluoxetine is prescribed can also be associated with an increased risk of suicide-related events. In addition, these conditions may be co-morbid with major depressive disorder. The same precautions observed when treating patients with major depressive disorder should therefore be observed when treating patients with other psychiatric disorders.
Patients with a history of suicide-related events, or those exhibiting a significant degree of suicidal ideation prior to commencement of treatment are known to be at a greater risk of suicidal thoughts or suicide attempts, and should receive careful monitoring during treatment. A meta-analysis of placebo-controlled clinical trials of antidepressant drugs in adult patients with psychiatric disorders showed an increased risk of suicidal behaviour with antidepressants compared to placebo in patients less than 25 years old.
Close supervision of patients and in particular those at high risk should accompany drug therapy especially in early treatment and following dose changes.
Patients (and caregivers of patients) should be alerted about the need to monitor for any clinical worsening, suicidal behaviour or thoughts and unusual changes in behaviour and to seek medical advice immediately if these symptoms present.
\*Akathisia / psychomotor restlessness:\* The use of fluoxetine has been associated with the development of akathisia, characterised by a subjectively unpleasant or distressing restlessness and need to move often accompanied by an inability to sit or stand still. This is most likely to occur within the first few weeks of treatment. In patients who develop these symptoms, increasing the dose may be detrimental.
\*Withdrawal symptoms seen on discontinuation of SSRI treatment:\* Withdrawal symptoms when treatment is discontinued are common, particularly if discontinuation is abrupt (see section 4.8). In clinical trials adverse events seen on treatment discontinuation occurred in approximately 60 % of patients in both fluoxetine and placebo groups. Of these adverse events, 17 % in the fluoxetine group and 12 % in the placebo group were severe in nature.
The risk of withdrawal symptoms may be dependent on several factors including the duration and dose of therapy and the rate of dose reduction. Dizziness, sensory disturbances (including paraesthesia), sleep disturbances (including insomnia and intense dreams), asthenia, agitation or anxiety, nausea and / or vomiting, tremor and headache are the most commonly reported reactions. Generally these symptoms are mild to moderate, however, in some patients they may be severe in intensity. They usually occur within the first few days of discontinuing treatment. Generally these symptoms are self-limiting and usually resolve within 2 weeks, though in some individuals they may be prolonged (2-3 months or more). It is therefore advised that fluoxetine should be gradually tapered when discontinuing treatment over a period of at least one to two weeks, according to the patient's needs (see “Withdrawal Symptoms Seen on Discontinuation of Fluoxetine, section 4.2).
\*Haemorrhage:\* There have been reports of cutaneous bleeding abnormalities, such as ecchymosis and purpura, with SSRIs. Ecchymosis has been reported as an infrequent event during treatment with fluoxetine. Other haemorrhagic manifestations (e.g., gynaecological haemorrhages, gastro-intestinal bleedings, and other cutaneous or mucous bleedings) have been reported rarely. Caution is advised in patients taking SSRIs, particularly in concomitant use with oral anticoagulants, drugs known to affect platelet function (e.g., atypical antipsychotics, such as clozapine, phenothiazines, most TCAs, aspirin, NSAIDs), or other drugs that may increase risk of bleeding, as well as in patients with a history of bleeding disorders (see section 4.5).
SSRIs/SNRIs may increase the risk of postpartum haemorrhage (see sections 4.6, 4.8)
\*Mydriasis:\* Mydriasis has been reported in association with fluoxetine; therefore, caution should be used when prescribing fluoxetine in patients with raised intraocular pressure or those at risk of acute narrow angle glaucoma.
\*Electroconvulsive therapy (ECT):\* There have been rare reports of prolonged seizures in patients on fluoxetine receiving ECT treatment, therefore caution is advisable.
\*Serotonin syndrome or neuroleptic malignant syndrome like events:\* On rare occasions, development of a serotonin syndrome or neuroleptic malignant syndrome-like events have been reported in association with treatment of fluoxetine, particularly when given in combination with other serotonergic (among others, L-tryptophan) and/or neuroleptic drugs (see section 4.5). As these syndromes may result in potentially life-threatening conditions, treatment with fluoxetine should be discontinued if such events (characterised by clusters of symptoms, such as hyperthermia, rigidity, myoclonus, autonomic instability with possible rapid fluctuations of vital signs, mental status changes, including confusion, irritability, extreme agitation, progressing to delirium and coma) occur, and supportive symptomatic treatment should be initiated.
Concomitant administration of buprenorphine/opioids and other serotonergic agents, such as MAO inhibitors, selective serotonin re-uptake inhibitors (SSRIs), serotonin norepinephrine re-uptake inhibitors (SNRIs) or tricyclic antidepressants may result in serotonin syndrome, a potentially life-threatening condition (see section 4.5).
If concomitant treatment with buprenorphine/opioids and other serotonergic agents is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose increases.
Symptoms of serotonin syndrome may include mental-status changes, autonomic instability, neuromuscular abnormalities, and/or gastrointestinal symptoms.
If serotonin syndrome is suspected, a dose reduction or discontinuation of therapy should be considered depending on the severity of the symptoms.
\*Sexual dysfunction:\*
Selective serotonin reuptake inhibitors (SSRIs)/serotonin norepinephrine reuptake inhibitors (SNRIs) may cause symptoms of sexual dysfunction (see section 4.8). There have been reports of long-lasting sexual dysfunction where the symptoms have continued despite discontinuation of SSRIs/SNRI.4.5 Interaction with other medicinal products and other forms of interaction
\*\*Paediatric population\*\*
Interaction studies have only been performed in adults.
\*Half-life:\* The long elimination half-lives of both fluoxetine and norfluoxetine should be borne in mind (see section 5.2) when considering pharmacodynamic or pharmacokinetic drug interactions (e.g., when switching from fluoxetine to other antidepressants).
\*\*Contra-indicated combinations\*\*
Irreversible, non-selective monoamine oxidase inhibitors (e.g. iproniazid): Some cases of serious and sometimes fatal reactions have been reported in patients receiving an SSRI in combination with an irreversible, non-selective monoamine oxidase inhibitor (MAOI).
These cases presented with features resembling serotonin syndrome (which may be confounded with [or diagnosed as] neuroleptic malignant syndrome). Cyproheptadine or dantrolene may benefit patients experiencing such reactions. Symptoms of a drug interaction with a MAOI include: hyperthermia, rigidity, myoclonus, autonomic instability with possible rapid fluctuations of vital signs, mental status changes that include confusion, irritability and extreme agitation progressing to delirium and coma.
Therefore, fluoxetine is contra-indicated in combination with an irreversible, non-selective MAOI (see section 4.3). Because of the two weeks-lasting effect of the latter, treatment of fluoxetine should only be started 2 weeks after discontinuation of an irreversible, non-selective MAOI. Similarly, at least 5 weeks should elapse after discontinuing fluoxetine treatment before starting an irreversible, non-selective MAOI.
Metoprolol used in cardiac failure: risk of metoprolol adverse events, including excessive bradycardia, may be increased because of an inhibition of its metabolism by fluoxetine (see section 4.3).
\*\*Not recommended combinations\*\*
Tamoxifen: Pharmacokinetic interaction between CYP2D6 inhibitors and tamoxifen, showing a 65-75 % reduction in plasma levels of one of the more active forms of the tamoxifen, i.e. endoxifen, has been reported in the literature. Reduced efficacy of tamoxifen has been reported with concomitant usage of some SSRI antidepressants in some studies. As a reduced effect of tamoxifen cannot be excluded, co-administration with potent CYP2D6 inhibitors (including fluoxetine) should whenever possible be avoided (see section 4.4).
Alcohol: In formal testing, fluoxetine did not raise blood alcohol levels or enhance the effects of alcohol. However, the combination of SSRI treatment and alcohol is not advisable.
MAOI-A including linezolid and methylthioninium chloride (methylene blue): Risk of serotonin syndrome including diarrhoea, tachycardia, sweating, tremor, confusion or coma. If the concomitant use of these active substances with fluoxetine cannot be avoided, close clinical monitoring should be undertaken and the concomitant agents should be initiated at the lower recommended doses (see section 4.4).
Mequitazine: risk of mequitazine adverse events (such as QT prolongation) may be increased because of an inhibition of its metabolism by fluoxetine.
\*\*Combinations requiring caution\*\*
Fluoxetine should be used cautiously when co-administered with:
Buprenorphine/opioids, as the risk of serotonin syndrome, a potentially life-threatening condition, is increased (see section 4.4).
Phenytoin: Changes in blood levels have been observed when combined with fluoxetine. In some cases manifestations of toxicity have occurred. Consideration should be given to using conservative titration schedules of the concomitant drug and to monitoring clinical status.
Serotoninergic drugs (lithium, tramadol, triptans, tryptophan, selegiline (MAOI-B), St. John's Wort (Hypericum perforatum)): There have been reports of mild serotonin syndrome when SSRIs were given with drugs also having a serotoninergic effect. Therefore, the concomitant use of fluoxetine with these drugs should be undertaken with caution, with closer and more frequent clinical monitoring (see section 4.4).
QT interval prolongation: Pharmacokinetic and pharmacodynamic studies between fluoxetine and other medicinal products that prolong the QT interval have not been performed. An additive effect of fluoxetine and these medicinal products cannot be excluded. Therefore, co-administration of fluoxetine with medicinal products that prolong the QT interval, such as Class IA and III antiarrhythmics, antipsychotics (e.g. phenothiazine derivatives, pimozide, haloperidol), tricyclic antidepressants, certain antimicrobial agents (e.g. sparfloxacin, moxifloxacin, erythromycin IV (intravenous), pentamidine), anti-malaria treatment particularly halofantrine, certain antihistamines (astemizole, mizolastine), should be used with caution (see sections 4.4, 4.8 and 4.9).
Drugs affecting haemostasis (oral anticoagulants, whatever their mechanism, platelets antiaggregants including aspirin and non-steroidal anti-inflammatory drugs ( NSAIDs)): risk of increased bleeding. Clinical monitoring, and more frequent monitoring of INR with oral anticoagulants, should be made. A dose adjustment during the fluoxetine treatment and after its discontinuation may be suitable (see sections 4.4 and 4.8).
Cyproheptadine: There are individual case reports of reduced antidepressant activity of fluoxetine when used in combination with cyproheptadine.
Drugs inducing hyponatremia: Hyponatremia is an undesirable effect of fluoxetine. Use in combination with other agents associated with hyponatremia (e.g. diuretics, desmopressin, carbamazepine and oxcarbazepine) may lead to an increased risk (see section 4.8).
Drugs lowering the epileptogenic threshold: Seizures are an undesirable effect of fluoxetine. Use in combination with other agents which may lower the seizure threshold (for example, tricyclic antidepressants (TCAs), other SSRIs, phenothiazines, butyrophenones, mefloquine, chloroquine, bupropion, tramadol) may lead to an increased risk.
Other drugs metabolised by CYP2D6 isoenzyme: Fluoxetine is a strong inhibitor of CYP2D6 enzyme, therefore concomitant therapy with drugs also metabolised by this enzyme system may lead to drug interactions, notably those having a narrow therapeutic index (such as flecainide, encainide, vinblastine, propafenone and nebivolol) and those that are titrated, but also with atomoxetine, carbamazepine, tricyclic antidepressants and risperidone. They should be initiated at or adjusted to the low end of their dose range. This may also apply if fluoxetine has been taken in the previous 5 weeks.
Greater than two-fold increases of previously stable plasma levels of TCAs have been observed when administered in combination with Fluoxetine.4.6 Fertility, pregnancy and lactation
\*Pregnanc\*y: Fluoxetine should not be used during pregnancy unless the clinical condition of the woman requires treatment with fluoxetine and justifies the potential risk to the foetus. Abrupt discontinuation of therapy should be avoided during pregnancy (see section 4.2 "Posology and method of administration"). Furthermore, although fluoxetine can be used during pregnancy, but caution should be exercised when prescribing to pregnant women, especially during late pregnancy or just prior to the onset of labour, since the following effects have been reported in neonates: irritability, tremor, hypotonia, persistent crying, difficulty in sucking or in sleeping. These symptoms may indicate either serotonergic effects or a withdrawal syndrome. The time to occur and the duration of these symptoms may be related to the long half-life of fluoxetine (4-6 days) and its active metabolite, norfluoxetine (4-16 days).
Epidemiological data have suggested that the use of SSRIs in pregnancy, particular in late pregnancy, may increase the risk of persistent pulmonary hypertension in the newborn(PPHN). The observed risk was approximately 5 cases per 1000 pregnancies. In the general population 1 to 2 cases of PPHN per 1000 pregnancies occur.
Some epidemiological studies suggest an increased risk of cardiovascular defects associated with the use of fluoxetine during the first trimester. The mechanism is unknown. Overall the data suggest that the risk having an infant with a cardiovascular defect following maternal fluoxetine exposure is in the region of 2/100 compared with an expected rate for such defects of approximately 1/100 in the general population.
Observational data indicate an increased risk (less than 2-fold) of postpartum haemorrhage following SSRI/SNRI exposure within the month prior to birth (see sections 4.4, 4.8).
\*Breast-feeding:\* Fluoxetine and its metabolite, norfluoxetine, are known to be excreted in human breast milk. Adverse events have been reported in breast-feeding infants. If treatment with fluoxetine is considered necessary, discontinuation of breast-feeding should be considered; however, if breast-feeding is continued, the lowest effective dose of fluoxetine should be prescribed.
\*Fertility:\* Animal data have shown that fluoxetine may affect sperm quality (see section 5.3).
Human case reports with some SSRIs have shown that an effect on sperm quality is reversible.
Impact on human fertility has not been observed so far.4.7 Effects on ability to drive and use machines
Fluoxetine has no or negligible influence on the ability to drive and use machine. Although fluoxetine has been shown not to affect psychomotor performance in healthy volunteers, any psychoactive drug may impair judgement or skills. Patients should be advised to avoid driving a car or operating hazardous machinery until they are reasonably certain that their performance is not affected.4.8 Undesirable effects
\*a. Summary of the safety profile:\*
The most commonly reported adverse reactions in patients treated with fluoxetine were headache, nausea, insomnia, fatigue and diarrhoea.
Undesirable effects may decrease in intensity and frequency with continued treatment and do not generally lead to cessation of therapy.
\*b. Tabulated list of adverse reactions:\*
The table below gives the adverse reactions observed with fluoxetine treatment in adult and paediatric populations. Some of these adverse reactions are in common with other SSRIs.
The following frequencies have been calculated from clinical trials in adults (n = 9297) and from spontaneous reporting.
Frequency estimate: Very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1,000 to <1/100), rare (≥1/10,000), very rare (<1/10,000); not known (frequency cannot be estimated from the available data).
| | | | | | |
| --- | --- | --- | --- | --- | --- |
| Very Common | Common | Uncommon | Rare | Very rare | Not known |
| \*Blood and lymphatic system disorders\* | | | | | |
| | | | Thrombocytopenia Neutropenia Leucopenia | | |
| \*Immune system disorders\* | | | | | |
| | | | Anaphylactic reaction | | |
| | | | Serum sickness | | |
| \*Endocrine disorders\* | | | | | |
| | | | Inappropriate antidiuretic hormone secretion | | |
| \*Metabolism and nutrition disorders\* | | | | | |
| | Decreased appetite1 | | Hyponatraemia | | |
| \*Psychiatric disorders\* | | | | | |
| Insomnia2 | Anxiety Nervousness Restlessness Tension Libido decreased3 Sleep disorder Abnormal dreams4 | Depersonalisation Elevated mood Euphoric mood Thinking abnormal Orgasm abnormal5 Bruxism Suicidal thoughts and behaviour 6 | Hypomania Mania Hallucinations Agitation Panic attacks Confusion Dysphemia Aggression | | |
| \*Nervous system disorders\* | | | | | |
| Headache | Disturbance in attention Dizziness Dysgeusia Lethargy Somnolence7 Tremor | Psychomotor hyperactivity Dyskinesia Ataxia Balance disorder Myoclonus Memory impairment | Convulsion Akathisia Buccoglossal syndrome Serotonin syndrome | | |
| \*Eye disorders\* | | | | | |
| | Vision blurred | Mydriasis | | | |
| \*Ear and labyrinth disorders\* | | | | | |
| | | Tinnitus | | | |
| \*Cardiac disorders\* | | | | | |
| | Palpitations Electrocardiogram QT prolonged (QTcF ≥450 msec)8 | | Ventricular arrhythmia including torsade de pointes | | |
| \*Vascular disorders\* | | | | | |
| | Flushing9 | Hypotension | Vasculitis Vasodilatation | | |
| \*Respiratory, thoracic and mediastinal disorders\* | | | | | |
| | Yawning | Dyspnoea Epistaxis | Pharyngitis Pulmonary events (inflammatory processes of varying histopathology and/or fibrosis) 10 | | |
| \*Gastrointestinal disorders\* | | | | | |
| Diarrhoea Nausea | Vomiting Dyspepsia Dry mouth | Dysphagia Gastrointestinal haemorrhage11 | Oesophageal pain | | |
| \*Hepato-biliary disorders\* | | | | | |
| | | | Idiosyncratic hepatitis | | |
| \*Skin and subcutaneous tissue disorders\* | | | | | |
| | Rash12 Urticaria Pruritus Hyperhidrosis | Alopecia Increased tendency to bruise Cold sweat | Angioedema Ecchymosis Photosensitivity reaction Purpura Erythema multiforme Stevens-Johnson syndrome Toxic Epidermal Necrolysis (Lyell Syndrome) | | |
| \*Musculoskeletal and connective tissue disorders\* | | | | | |
| | Arthralgia | Muscle twitching | Myalgia | | |
| \*Renal and urinary disorders\* | | | | | |
| | Frequent urination13 | Dysuria | Urinary retention Micturition disorder | | |
| \*Reproductive system and breast disorders\* | | | | | |
| | Gynaecological bleeding14 Erectile dysfunction Ejaculation disorder15 | Sexual dysfunction | Galactorrhoea Hyperprolactinemia Priapism | | postpartum haemorrhage\\* |
| \*General disorders and administration site conditions\* | | | | | |
| Fatigue16 | Feeling jittery Chills | Malaise Feeling abnormal Feeling cold Feeling hot | Mucosal haemorrhage | | |
| \*Investigations\* | | | | | |
| | Weight decreased | Transaminases increased Gamma-glutamyltransferase increased | | | |
1 Includes anorexia
2 Includes early morning awakening, initial insomnia, middle insomnia
3 Includes loss of libido
4 Includes nightmares
5 Includes anorgasmia
6 Includes completed suicide, depression suicidal, intentional self-injury, self-injurious ideation, suicidal behaviour, suicidal ideation, suicide attempt, morbid thoughts, self-injurious behaviour. These symptoms may be due to underlying disease
7 Includes hypersomnia, sedation
8 Based on ECG measurements from clinical trials
9 Includes hot flush
10 Includes atelectasis, interstitial lung disease, pneumonitis
11 Includes most frequently gingival bleeding, haematemesis, haematochezia, rectal haemorrhage, diarrhea, haemorrhagic, melaena, and gastric ulcerhaemorrhage
12 Includes erythema, exfoliative rash, heat rash, rash, rash erythematous, rash follicular, rash generalized, rash macular, rash macular-papular, rash morbilliform, rash papular, rash pruritic, rash vesicular, umbilical erythema rash
13 Includes pollakiuria
14 Includes cervix haemorrhage, uterine dysfunction, uterine bleeding, genital haemorrhage, menometrorhagia, menorrhagia, metrorrhagia, polymenorrhea, postmenopausal haemorrhage, uterine haemorrhage, vaginal haemorrhage
15 Includes ejaculation failure, ejaculation dysfunction, premature ejaculation, ejaculation delayed, retrograde ejaculation
16 Includes asthenia
\\* This event has been reported for the therapeutic class of SSRIs/SNRIs (see sections 4.4, 4.6).
\*\*\*\*Description of selected adverse reactions\*\*\*\*
\*Suicide/suicidal thoughts or clinical worsening\*: Cases of suicidal ideation and suicidal behaviour have been reported during fluoxetine therapy or early after treatment discontinuation (see section 4.4).
\*Bone fractures:\* Epidemiological studies, mainly conducted in patients 50 years of age and older, show an increased risk of bone fractures in patients receiving SSRIs and TCAs. The mechanism leading to this risk is unknown.
\*\*\*\*Withdrawal symptoms seen on discontinuation of SSRI treatment\*\*\*\*
Discontinuation of fluoxetine (particularly when abrupt) commonly leads to withdrawal symptoms. Dizziness, sensory disturbances (including paraesthesia), sleep disturbances (including insomnia and intense dreams), asthenia, agitation or anxiety, nausea and/or vomiting, tremor and headache are the most commonly reported reactions. Generally these events are mild to moderate and are self-limiting, however, in some patients they may be severe and/or prolonged (see section 4.4). It is therefore advised that when fluoxetine treatment is no longer required, gradual discontinuation by dose tapering should be carried out (see section 4.2 and 4.4).
\*\*\*\*Paediatric population (see sections 4.4 and 5.1)\*\*\*\*
Adverse reactions that have been observed specifically or with a different frequency in this population are described below. Frequencies for these events are based on paediatric clinical trial exposures (n = 610).
In paediatric clinical trials, suicide-related behaviours (suicide attempt and suicidal thoughts), hostility (the events reported were: anger, irritability, aggression, agitation, activation syndrome), manic reactions, including mania and hypomania (no prior episodes reported in these patients) and epistaxis, were commonly reported and were more frequently observed among children and adolescents treated with antidepressants compared to those treated with placebo.
Isolated cases of growth retardation have been reported from clinical use (See also section 5.1).
In paediatric clinical trials, fluoxetine treatment was also associated with a decrease in alkaline phosphatase levels.
Isolated cases of adverse events potentially indicating delayed sexual maturation or sexual dysfunction have been reported from paediatric clinical use (See also section 5.3).
\*\*\*\*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 www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.4.9 Overdose
\*Symptoms\*
Cases of overdose of fluoxetine alone usually have a mild course. Symptoms of overdose have included nausea, vomiting, agitation, tremor, nystagmus, drowsiness seizures, cardiovascular dysfunction ranging from asymptomatic arrhythmias (including nodal rhythm and ventricular arrhythmias) or ECG changes indicative of QTc prolongationto cardiac arrest (including very rare cases of Torsade de Pointes), pulmonary dysfunction, and signs of altered CNS status ranging from excitation to coma. Fatality attributed to overdose of fluoxetine alone has been extremely rare.
\*Management\*
Cardiac and vital signs monitoring are recommended, along with general symptomatic and supportive measures. No specific antidote is known.
Forced diuresis, dialysis, haemoperfusion, and exchange transfusion are unlikely to be of benefit. Activated charcoal, which may be used with sorbitol, may be as or more effective than emesis or lavage. In managing overdosage, consider the possibility of multiple drug involvement. An extended time for close medical observation may be needed in patients who have taken excessive quantities of a tricyclic antidepressant if they are also taking, or have recently taken, fluoxetine.
## Pharmacological Properties
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: selective serotonin reuptake inhibitors (SSRI) ATC code: N06AB03
\*\*Mechanism of action\*\*
Fluoxetine is a selective inhibitor of serotonin reuptake, and this probably accounts for the mechanism of action. Fluoxetine has practically no affinity to other receptors such as α1-, α2-, and β-adrenergic; serotonergic; dopaminergic; histaminergic1; muscarinic; and GABA receptors.
\*\*Clinical efficacy and safety\*\*
\*Major depressive episodes:\* Clinical trials in patients with major depressive episodes have been conducted versus placebo and active controls. Fluoxetine has been shown to be significantly more effective than placebo, as measured by the Hamilton Depression Rating Scale (HAM-D). In these studies, Fluoxetine produced a significantly higher rate of response (defined by a 50% decrease in the HAM-D score) and remission, compared to placebo.
\*Dose response:\* In the fixed dose studies of patients with major depression there is a flat dose response curve, providing no suggestion of advantage in terms of efficacy for using higher than the recommended doses. However, it is clinical experience that up titrating might be beneficial for some patients.
\*Obsessive-compulsive disorder:\* In short-term trials (under 24 weeks), fluoxetine was shown to be significantly more effective than placebo. There was a therapeutic effect at 20mg/day, but higher doses (40 or 60mg/day) showed a higher response rate. In long-term studies (three short-term studies extension phase and a relapse prevention study) efficacy has not been shown.
\*Bulimia nervosa:\* In short-term trials (under 16 weeks), in out-patients fulfilling DSM-III-R-criteria for bulimia nervosa, fluoxetine 60mg/day was shown to be significantly more effective than placebo for the reduction of bingeing and purging activities. However, for long-term efficacy no conclusion can be drawn.
\*Pre-Menstrual Dysphoric Disorder\*:Two placebo-controlled studies were conducted in patients meeting Pre-Menstrual Dysphoric Disorder (PMDD) diagnostic criteria according to DSM-IV. Patients were included if they had symptoms of sufficient severity to impair social and occupational function and relationships with others. Patients using oral contraceptives were excluded. In the first study of continuous 20mg daily dosing for 6 cycles, improvement was observed in the primary efficacy parameter (irritability, anxiety, and dysphoria). In the second study, with intermittent luteal phase dosing (20mg daily for 14 days) for 3 cycles, improvement was observed in the primary efficacy parameter (Daily Record of Severity of Problems score). However, definitive conclusions on efficacy and duration of treatment cannot be drawn from these studies.
\*\*Paediatric population\*\*
\*Major depressive episodes (children and adolescents):\* Clinical trials in children and adolescents aged 8 years and above have been conducted versus placebo. Fluoxetine, at a dose of 20mg, has been shown to be significantly more effective than placebo in two short-term pivotal studies, as measured by the reduction of Childhood Depression Rating Scale-Revised (CDRS-R) total scores and Clinical Global Impression of Improvement (CGI-I) scores. In both studies, patients met criteria for moderate to severe MDD (DSM-III or DSM-IV) at three different evaluations by practising child psychiatrists. Efficacy in the fluoxetine trials may depend on the inclusion of a selective patient population (one that has not spontaneously recovered within a period of 3-5 weeks and whose depression persisted in the face of considerable attention). There is only limited data on safety and efficacy beyond 9 weeks. In general, efficacy of fluoxetine was modest. Response rates (the primary endpoint, defined as a 30% decrease in the CDRS-R score) demonstrated a statistically significant difference in one of the two pivotal studies (58% for fluoxetine versus 32% for placebo, \*P\* = 0.013; and 65% for fluoxetine versus 54% for placebo, \*P\* = 0.093). In these two studies, the mean absolute changes in CDRS-R from baseline to endpoint were 20 for fluoxetine versus 11 for placebo, \*P\* = 0.002; and 22 for fluoxetine versus 15 for placebo, \*P\* <0.001.
\*Effects on growth, see sections 4.4 and 4.8:\* After 19 weeks of treatment, paediatric subjects treated with fluoxetine in a clinical trial gained an average of 1.1 cm less in height (p=0.004) and 1.1 kg less in weight (p=0.008) than subjects treated with placebo.
In a retrospective matched control observational study with a mean of 1.8 years of exposure to fluoxetine, paediatric subjects treated with fluoxetine had no difference in growth adjusted for expected growth in height from their matched, untreated controls (0.0 cm, p=0.9673).5.2 Pharmacokinetic properties
\*Absorption:\* Fluoxetine is well absorbed from the gastro-intestinal tract after oral administration. The bioavailability is not affected by food intake.
\*Distribution:\* Fluoxetine is extensively bound to plasma proteins (about 95%) and it is widely distributed (volume of distribution: 20-40 l/kg). Steady-state plasma concentrations are achieved after dosing for several weeks. Steady-state concentrations after prolonged dosing are similar to concentrations seen at 4 to 5 weeks. When dosing is stopped, active drug substances will persist in the body for weeks. This should be borne in mind when starting or stopping treatment. Plasma concentrations do not appear to increase without limit because, in addition to metabolism by the hepatic cytochrome P450IID6 isoenzyme system, there are non-saturable pathways. Patients receiving fluoxetine for as long as 3 years exhibited average plasma concentrations, similar to those seen among patients treated for 4 or 5 weeks.
\*Biotransformation:\* Fluoxetine has a non-linear pharmacokinetic profile with first pass liver effect. Maximum plasma concentration is generally achieved 6 to 8 hours after administration. Fluoxetine is extensively metabolised by the polymorphic enzyme CYP2D6. Fluoxetine is primarily metabolised by the liver to the active metabolite norfluoxetine (desmethylfluoxetine), by desmethylation.
\*Elimination:\* Fluoxetine has a half-life of 1 to 3 days after acute administration. The half-life may be prolonged to 4 to 6 days after chronic administration. The active metabolite, norfluoxetine, has a mean half-life of 9.3 days after multiple dosing (range 4 to 16 days). These long half-lives are responsible for persistence of the drug for 5-6 weeks after discontinuation. Excretion is mainly (about 60%) via the kidney. Fluoxetine is secreted into breast milk.
\*Special populations\*
\*Elderly:\* Kinetic parameters are not altered in healthy elderly when compared to younger subjects.
\*Paediatric:\* The mean fluoxetine concentration in children is approximately 2-fold higher than that observed in adolescents and the mean norfluoxetine concentration 1.5-fold higher. Steady-state plasma concentrations are dependent on body weight and are higher in lower weight children (see section 4.2). As in adults, fluoxetine and norfluoxetine accumulated extensively following multiple oral dosing; steady-state concentrations were achieved within 3 to 4 weeks of daily dosing.
\*Hepatic impairment:\* In case of hepatic insufficiency (alcoholic cirrhosis), fluoxetine and norfluoxetine half-lives are increased to 7 and 12 days, respectively. A lower or less frequent dose should be considered.
\*Renal impairment:\* After single-dose administration of fluoxetine in patients with mild, moderate, or complete (anuria) renal insufficiency, kinetic parameters have not been altered when compared to healthy volunteers. However, after repeated administration, an increase in steady-state plateau of plasma concentrations may be observed.5.3 Preclinical safety data
There is no evidence of carcinogenicity, mutagenicity, or impairment of fertility from \*in vitro\* or animal studies.
\*Adult animal studies\*
In a 2-generation rat reproduction study, fluoxetine did not produce adverse effects on the mating or fertility of rats, was not teratogenic, and did not affect growth, development, or reproductive parameters of the offspring.
The concentrations in the diet provided doses approximately equivalent to 1.5, 3.9, and 9.7 mg fluoxetine/kg body weight.
Male mice treated daily for 3 months with fluoxetine in the diet at a dose approximately equivalent to 31 mg/kg showed a decrease in testis weight and hypospermatogenesis. However, this dose level exceeded the maximum-tolerated dose (MTD) as significant signs of toxicity were seen.
\*\*\*Juvenile animal studies\*\*\*
In a juvenile toxicology study in CD rats, administration of 30 mg/kg/day of fluoxetine hydrochloride on postnatal days 21 to 90 resulted in irreversible testicular degeneration and necrosis, epididymal epithelial vacuolation, immaturity and inactivity of the female reproductive tract and decreased fertility. Delays in sexual maturation occurred in males (10 and 30 mg/kg/day) and females (30 mg/kg/day). The significance of these findings in humans is unknown. Rats administered 30 mg/kg also had decreased femur lengths compared with controls and skeletal muscle degeneration, necrosis and regeneration. At 10 mg/kg/day, plasma levels achieved in animals were approximately 0.8 to 8.8 fold (fluoxetine) and 3.6 to 23.2 fold (norfluoxetine) those usually observed in paediatric patients. At 3 mg/kg/day, plasma levels achieved in animals were approximately 0.04 to 0.5 fold (fluoxetine) and 0.3 to 2.1 fold (norfluoxetine) those usually achieved in paediatric patients.
A study in juvenile mice has indicated that inhibition of the serotonin transporter prevents the accrual of bone formation. This finding would appear to be supported by clinical findings. The reversibility of this effect has not been established.
Another study in juvenile mice (treated on postnatal days 4 to 21) has demonstrated that inhibition of the serotonin transporter had long lasting effects on the behaviour of the mice. There is no information on whether the effect was reversible. The clinical relevance of this finding has not been established.
## Pharmaceutical Particulars
6.1 List of excipients
Pregelatinised maize starch
\*\*Capsule shell components\*\*
\*\*Body\*\*
Yellow iron oxide E 172
Titanium dioxide E 171
Gelatin
\*\*Cap\*\*
Brilliant blue E133
Yellow iron oxide E 172
Titanium dioxide E 171
Gelatin
\*\*Printing ink components\*\*
Activated charcoal and shellac (E904).6.2 Incompatibilities
Not applicable.6.3 Shelf life
42 Months6.4 Special precautions for storage
Do not store above 25°C.
Store in the original package in order to protect from moisture6.5 Nature and contents of container
10, 14, 20, 30, 50, 70 or 100 Capsules packed in PVC/PVdC Aluminium blister.
Not all pack sizes may be marketed.6.6 Special precautions for disposal and other handling
No special requirements
