- Approval Id
- eba740849bf6548b
- Drug Approval Emc Name
- Clobazam Atnahs 10mg/5ml Oral Suspension
- Drug Name
- Clobazam Atnahs 10mg/5ml Oral Suspension
- Company Name
- Atnahs Pharma UK Ltd
- Company Address
- Sovereign House, Miles Gray Road, Basildon, SS14 3FR
- Company Website
- //www.pharmanovia.com
- Company Telephone
- (+44) 01268 943 700
- Company Medical Info Direct Line
- (+44) 01268 943 700
- Company Medical Info Email
- medinfo@pharmanovia.com
- Company Customer Care Direct Line
- (+44) 01268 943 700
- Company Medical Info Fax
- +44(0)1748 828801
- Atc Code
- N05BA09
- Legal Category
- Prescription only medicine
- Authorisation Holder
- Atnahs Pharma UK Limited
Sovereign House
Miles Gray Road
Basildon
Essex
SS14 3FR
United Kingdom
- Authorisation Number
- PL 43252/0011
- Authorisation Date
- 22/11/2016
- Instruction Authorisation Holder
- Atnahs Pharma UK Limited
Sovereign House
Miles Gray Road
Basildon
Essex
SS14 3FR
United Kingdom
- Instruction Authorisation Number
- PL 43252/0011
- Instruction Authorisation Date
- 22/11/2016
- Instruction Composition
- Each 5 ml of suspension contains 10mg of clobazam
\*\*Excipients with known effect\*\*
Each 5 ml of suspension contains 875mg of sorbitol, 15.25mg of sodium, 10.25mg of sodium methyl parahydroxybenzoate (E219) and 1.12mg of sodium propyl parahydroxybenzoate.
For the full list of excipients, see section 6.1.
- Instruction Dosage Form
- Oral Suspension
An off white viscous suspension with an odour of raspberry
- Instruction Clinical Particulars
- 4.1 Therapeutic indications
Clobazam is a 1,5-benzodiazepine indicated for the short-term relief (2-4 weeks) only of anxiety that is severe, disabling or subjecting the individual to unacceptable distress, occurring alone or in association with insomnia or short term psychosomatic, organic or psychotic illness. The use of clobazam to treat short-term “mild” anxiety is inappropriate and unsuitable.
Before treatment of anxiety states associated with emotional instability, it must first be determined whether the patient suffers from a depressive disorder requiring adjunctive or different treatment. Indeed, in patients with anxiety associated with depression, clobazam must be used only in conjunction with adequate concomitant treatment. Use of benzodiazepine (such as clobazam) alone, can precipitate suicide in such patients.
In patients with schizophrenic or other psychotic illnesses, use of benzodiazepines is recommended only for adjunctive, i.e. not for primary treatment.
Clobazam may be used as adjunctive therapy in epilepsy in adults or children over 2 years of age, if standard treatment with one or more anticonvulsants has failed.
Clobazam oral suspension should only be used in children from 6 month to 2 years old, under exceptional situations, where there is a clear epilepsy indication.4.2 Posology and method of administration
\*\*Posology\*\*
If low doses are required, the 5 mg/5ml strength product is a more suitable presentation. If high doses are required, the 10 mg/5 ml strength product is a more suitable presentation.
For patients who require only small doses of less than 1ml, the 150ml pack size of the 5mg/5ml strength should be used, which is provided with a 1ml oral syringe.
\*\*Treatment of anxiety\*\*
Treatment should be as short as possible. The patient must be re-assessed after a period not exceeding 4 weeks and regularly thereafter in order to evaluate the need for continued treatment, especially where the patient is free of symptoms. Generally the overall duration of treatment (i.e. including tapering-off process) must not exceed 8 to 12 weeks.
In certain cases extension beyond the maximum treatment period may be necessary; if so it should not take place without re-evaluation of the patient's status with special expertise. It is strongly recommended that prolonged periods of uninterrupted treatment be avoided, since they may lead to dependance.
\*\*Adults:\*\*
The usual anxiolytic dose for adults is 20-30 mg daily in divided doses or as a single dose given at night. Doses up to 60mg daily have been used in the treatment of adult in-patients with severe anxiety.
The lowest dose that can control symptoms should be used. After improvement of the symptoms, the dose may be reduced.
It should not be used for longer than 4 weeks.
Due regard must be paid to the possibility of interference with alertness and reaction time.
Long term chronic use as an anxiolytic is not recommended. In certain cases, extension beyond the maximum treatment period may be necessary; treatment must not be extended without re-evaluation of the patient's status using special expertise. It is strongly recommended that prolonged periods of uninterrupted treatment be avoided, since they may lead to dependence. Treatment should always be withdrawn gradually. Patients who have taken clobazam for a long time may require a longer period during which doses are reduced.
\*\*Elderly:\*\*
Doses of 10-20 mg daily in anxiety may be used in the elderly, who are more sensitive to the effects of psychoactive agents. Treatment requires low initial doses and gradual dose increments under careful observation.
\*\*Treatment of epilepsy in association with one or more other anticonvulsants\*\*
The oral suspension is suitable for any epilepsy patient in whom the clinician feels an oral suspension is preferable to clobazam tablets.
In all cases, treatment should be initiated at the lowest effective dose with gradual dose increments under careful observation.
\*\*Adults\*\*
In epilepsy a starting dose of 20-30 mg/day is recommended, increasing as necessary up to a maximum of 60 mg daily.
\*\*Elderly\*\*
Treatment requires low initial doses and gradual dose increments under careful observation.
\*\*Paediatric patients aged 6 years and above:\*\*
When prescribed for children treatment requires low initial doses and gradual dose increments under careful observation. It is recommended that normally treatment should be started at 5mg daily. A maintenance dose of 0.3 to 1mg/kg body weight daily is usually sufficient.
\*\*Paediatric population aged 2 and above:\*\*
Initial: 5 mg/day (aged 6 years and above) or 0.1 mg/kg/day for younger patients. The dose may be increased slowly by steps of 0.1 to 0.2 mg/kg/day at 7 days intervals, until the required clinical effect is achieved or side effects occur.
Maintenance dose: usually 0.3 to 1 mg/kg/day. The daily dose can be taken in divided doses or as single dose at night.
\*\*Paediatric population aged between 6 months and 2 years:\*\*
Clobazam oral suspension should only be used in children from 6 month to 2 years old, under exceptional situations, when there is a clear epilepsy indication. Use 0.1mg/kg/day and titrate upwards very slowly (increasing not more often than every 5 days) to achieve required clinical effect, in divided doses twice daily.
The patient must be re-assessed after a period not exceeding 4 weeks and regularly thereafter in order to evaluate the need for continued treatment. A break in therapy may be beneficial if drug exhaustion develops, recommencing therapy at a low dose. At the end of treatment (including in poor-responding patients), since the risk of withdrawal phenomena/rebound phenomena is greater after abrupt discontinuation of treatment, it is recommended to gradually decrease the dosage.
Patients with impairment of renal or hepatic function: Increased responsiveness and higher susceptibility to adverse effects may be present in these patients and require low initial doses and gradual dose increments under careful observation. The maximum dose should not be exceeded.
The patient should be checked regularly at the start of the treatment in order to decrease if necessary, the dose or frequency of administration to prevent overdose due to accumulation.
\*\*Method of administration\*\*
For oral use only.
Once titrated to an effective dose of clobazam, patients should remain on their treatment and care should be exercised when changing between different formulations.4.3 Contraindications
Clobazam must not be used:
• In patients with hypersensitivity to the active substance, benzodiazepines or to any of the excipients listed in section 6.1.
• In patients with any history of drug or alcohol dependence (increased risk of development of dependence).
• In patients with myasthenia gravis (risk of aggravation of muscle weakness).
• In patients with severe respiratory insufficiency (risk of deterioration).
• In patients with sleep apnoea syndrome (risk of deterioration).
• In patients with severe hepatic insufficiencies (risk of precipitating encephalopathy).
• In breast-feeding women.
• During the first trimester of pregnancy (for use during second and third trimester, see section 4.6 ).
Benzodiazepines must not be given to children without careful assessment of the need for their use. Clobazam must not be used in children between the ages of 6 months to 2 years old, other than in exceptional cases for anticonvulsant treatment where there is a compelling indication. See section 4.2 for recommended dose titration advice in these circumstances.4.4 Special warnings and precautions for use
\*\*Amnesia\*\*
Benzodiazepines may induce anterograde amnesia. The condition occurs most often several hours after ingesting the product and therefore to reduce the risk patients should ensure that they will be able to have an uninterrupted sleep of 7-8 hours (see also Undesirable Effects).
\*\*Muscle weakness\*\*
Clobazam can cause muscle weakness. Special caution is necessary if clobazam is used in patients with myasthenia gravis, spinal or cerebellar ataxia or sleep apnoea. A dose reduction may be necessary. Clobazam is contraindicated in patients with myasthenia gravis.
\*\*Depression and personality disorders\*\*
Some epidemiological studies suggest an increased incidence of suicidal ideation, suicide attempt and suicide in patients with or without depression and treated with benzodiazepines and other hypnotics, including clobazam. However, a causal relationship has not been established (see section 4.8).
\*\*Dependence\*\*
Use of benzodiazepines - including clobazam - may lead to the development of physical and psychological dependence upon these products. The risk of dependence increases with dose and duration of treatment; it is also greater in patients with a history of alcohol or drug abuse. Therefore, the duration of treatment should be as short as possible (see section 4.2 Posology).
Once physical dependence has developed, abrupt termination of treatment will be accompanied by withdrawal symptoms (or rebound phenomena).
These may consist of headaches, muscle pain, extreme anxiety, tension, restlessness, confusion and irritability. In severe cases the following symptoms may occur; derealization, depersonalization, hyperacusis, numbness and tingling of the extremities, hypersensitivity to light, noise and physical contact, hallucinations or epileptic seizures.
Rebound insomnia and anxiety: a transient syndrome whereby the symptoms that led to treatment with a benzodiazepine recur in an enhanced form, may occur on withdrawal of treatment. It may be accompanied by other reactions including mood changes, anxiety or sleep disturbances and restlessness. Since the risk of withdrawal phenomena/rebound phenomena is greater after abrupt discontinuation of treatment, it is recommended that the dosage is decreased gradually.
\*\*Serious Skin Reactions\*\*
Serious skin reactions, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), have been reported with clobazam in both children and adults during the post-marketing experience. A majority of the reported cases involved the concomitant use of other drugs, including anti-epileptic drugs that are associated with serious skin reactions.
SJS/TEN could be associated with a fatal outcome. Patients should be closely monitored for signs or symptoms of SJS/TEN, especially during the first 8 weeks of treatment. Clobazam should be immediately discontinued when SJS/TEN is suspected. If signs or symptoms suggest SJS/TEN, use of this drug should not be resumed and alternative therapy should be considered (see section 4.8).
\*\*Respiratory Depression\*\*
A lower dose is also recommended for in patients with chronic or acute severe respiratory insufficiency due to the risk of respiratory depression (respiratory functions must be monitored and a dose reduction of clobazam may be necessary).
Clobazam is contraindicated in patients with severe respiratory insufficiency (please refer to section 4.3 Contraindications).
\*\*Renal and hepatic impairment\*\*
In patients with impairment of renal or hepatic function, responsiveness to clobazam and susceptibility to adverse effects are increased, and a dose reduction may be necessary. In long-term treatment renal and hepatic function must be checked regularly.
Benzodiazepines are not indicated to treat patients with severe hepatic insufficiency as they may precipitate encephalopathy.
\*\*Elderly patients\*\*
In the elderly, due to the increased sensitivity to adverse reactions such as drowsiness, dizziness, muscle weakness, there is an increased risk of fall that may result in serious injury. A dose reduction is recommended.
\*\*Tolerance in epilepsy\*\*
Some loss of efficacy to the hypnotic effects of benzodiazepines may develop after repeated use for a few weeks.
In the treatment of epilepsy with benzodiazepines - including clobazam - consideration must be given to the possibility of a decrease in anti-convulsant efficacy (development of tolerance) in the course of treatment.
\*\*CYP2C19 poor metabolisers\*\*
In patients who are CYP2C19 poor metabolisers, levels of the active metabolite N-desmethylclobazam are expected to be increased as compared to extensive metabolisers. As this may lead to increased side effects, dosage adjustment of clobazam may be necessary (e.g. low starting dose with careful dose titration (see section 5.2).
\*\*Alcohol\*\*
It is recommended that patients abstain from drinking alcohol during treatment with clobazam (increased risk of sedation and other adverse effects) (see section 4.5).
Benzodiazepines including clobazam, should be used with extreme caution in patients with a history of alcohol or drug abuse.
\*\*Concomitant use of opioids and benzodiazepines\*\*
Concomitant use of clobazam and opioids may result in sedation, respiratory depression, coma and death. Because of these risks, concomitant prescribing of benzodiazepines such as clobazam with opioids should be reserved for patients for whom alternative treatment options are not possible. If a decision is made to prescribe clobazam concomitantly with opioids, the lowest effective dose should be used, and the duration of treatment should be as short as possible (see also general dose recommendation in section 4.2).
The patients should be followed closely for signs and symptoms of respiratory depression and sedation. In this respect, it is strongly recommended to inform patients and their caregivers (where applicable) to be aware of these symptoms (see section 4.5).
In the treatment of epilepsy with benzodiazepines - including clobazam - consideration must be given to the possibility of a decrease in anticonvulsant efficacy (development of tolerance) in the course of treatment.
\*\*Concomitant use of cannabidiol\*\*
The concomitant use of clobazam with cannabidiol-containing medicinal and non-medicinal products may result in increased exposure to N-desmethylclobazam, leading to increased incidence of somnolence and sedation. Dosage adjustment of clobazam may be necessary. Non-medicinal products containing cannabidiol must not be taken in combination with clobazam as they contain unknown quantities of cannabidiol and are of variable quality (see sections 4.5 and 5.2).
\*\*Excipient in the formulation\*\*
Clobazam Oral Suspension contains sorbitol. Patients with rare hereditary problems of fructose intolerance should not take this medicine.
The medicine also contains sodium methyl and propyl parahydroxybenzoates which may cause allergic reactions. The signs may include a rash, swallowing or breathing problems and swelling of the lips, face, throat or tongue.
Sodium - contains 3.05 mg/ml. this should be taken into account by patients on a low sodium diet.
\*\*Risks from concomitant use of opioids and benzodiazepines\*\*
Concomitant use of Clobazam and opioids may result in sedation, respiratory depression, coma and death. Because of these risks, concomitant prescribing of sedative medicines such as benzodiazepines or related drugs such as Clobazam with opioids should be reserved for patients for whom alternative treatment options are not possible.
If a decision is made to prescribe Clobazam concomitantly with opioids, the lowest effective dose should be used, and the duration of treatment should be as short as possible (see also general dose recommendation in section 4.2). The patients should be followed closely for signs and symptoms of respiratory depression and sedation. In this respect, it is strongly recommended to inform patients and their environment to be aware of these symptoms (see section 4.5).
\*\*Duration of treatment\*\*
The duration of treatment should be as short as possible (see Posology). Extension beyond these periods should not take place without revaluation of the situation.
It may be useful to inform the patient when treatment is started that it will be of limited duration and to explain precisely how the dosage will be progressively decreased. Moreover it is important that the patient should be aware of the possibility of rebound phenomena, thereby minimising anxiety over such symptoms should they occur while the medicinal product is being discontinued.
There are indications that, in the case of benzodiazepines with a short duration of action, withdrawal phenomena can become manifest within the dosage interval, especially when the dosage is high. When benzodiazepines with a long duration of action are being used (for example Frisium) it is important to warn against changing to a benzodiazepine with a short duration of action, as withdrawal symptoms may develop.
\*\*Psychiatric and 'paradoxical' reactions\*\*
Reactions like restlessness, agitation, irritability, aggressiveness, delusion, rages, nightmares, hallucinations, psychoses, inappropriate behaviour and other adverse behavioural effects are known to occur when using benzodiazepines. Should this occur, use of the drug should be discontinued.
They are more likely to occur in children and the elderly.
Benzodiazepines are not recommended for the primary treatment of psychotic illness.
\*\*Specific patient groups\*\*
Benzodiazepines must not be given to children without careful assessment of the need for their use. Clobazam must not be used in children between the ages of 6 months and 3 years, other than in exceptional cases for anticonvulsants treatment where there is a compelling indication.
The duration of treatment must be kept to a minimum.4.5 Interaction with other medicinal products and other forms of interaction
\*\*Alcohol\*\*
Concomitant consumption of alcohol can increase the bioavailability of clobazam by 50% (see section 5.2) and therefore increase the effects of clobazam e.g. sedation (see section 4.5).
\*\*Central nervous system depressant drugs\*\*
Especially when clobazam is administered at higher doses, an enhancement of the central depressive effect may occur in cases of concomitant use with antipsychotics , hypnotics, anxiolytics/sedatives, antidepressant agents, narcotic analgesics, anti-convulsant drugs, anaesthetics and sedative antihistamines. Special caution is also necessary when clobazam is administered in cases of intoxication with such substances or with lithium.
\*\*Opioids\*\*
The concomitant use of sedative medicines such as benzodiazepines or related drugs such as Clobazam with opioids increases the risk of sedation, respiratory depression, coma and death because of additive CNS depressant effect. The dosage and duration of concomitant use should be limited (see section 4.4).
\*\*Anti-convulsants\*\*
Addition of clobazam to established anti-convulsant medication (e.g phenytoin, valproic acid) may cause a change in plasma levels of these drugs. If used as an adjuvant in epilepsy the dosage of clobazam should be determined by monitoring the EEG and the plasma levels of the other drugs checked.
Phenytoin and carbamazepine may cause an increase in the metabolic conversion of clobazam to the active metabolite N-desmethylclobazam, , which may result in adverse reactions.
Stiripentol increases plasma levels of clobazam and its active metabolite Ndesmethylclobazam, through inhibition of CYP3A and CYP2C19. Monitoring of blood levels is recommended, prior to initiation of stiripentol, and then once new steady-state concentration has been reached, i.e. after 2 weeks approximately.
\*\*Muscle relaxants\*\*
The effects of muscle relaxants, analgesics and nitrous oxide may be enhanced.
\*\*Narcotic analgesics\*\*
If clobazam is used concomitantly with narcotic analgesics, possible euphoria may be enhanced; this may lead to increased psychological dependence.
\*\*MAOIs\*\*
Concurrent treatment with drugs that inhibit the cytochrome P-450 enzyme (mono- oxygenase) system (e.g. cimetidine) may enhance and prolong the effect of clobazam.
\*\*CYP2C19 inhibitors\*\*
Strong and moderate inhibitors of CYP2C19 may result in increased exposure to N-desmethylclobazam (N-CLB), the active metabolite of clobazam. Dosage adjustment of clobazam may be necessary when co-administered with strong (e.g. fluconazole, fluvoxamine, ticlopidine) or moderate (e.g. omeprazole) CYP2C19 inhibitors (see Section 5.2).
\*\*CYP2D6 substrates\*\*
Clobazam is a weak CYP2D6 inhibitor. Dose adjustment of drugs metabolized by CYP2D6 (e.g. dextromethorphan, pimozide, paroxetine, nebivolol) may be necessary.
\*\*Cannabidiol\*\*
When cannabidiol and clobazam are co-administered, bi-directional PK interactions occur. Based on a healthy volunteer study, elevated levels (3- to 4-fold) of N-desmethylclobazam (an active metabolite of clobazam) can occur when combined with cannabidiol, likely mediated by CYP2C19 inhibition. Increased systemic levels of these active substances may lead to enhanced pharmacological effects and to an increase in adverse drug reactions. Concomitant use of cannabidiol and clobazam increases the incidence of somnolence and sedation. Reduction in dose of clobazam should be considered if somnolence or sedation are experienced when clobazam is co-administered with cannabidiol.4.6 Fertility, pregnancy and lactation
\*\*Pregnancy\*\*
There are limited amount of data from the use of clobazam in pregnant women.
Nevertheless, a large amount of data collected from cohort studies has not demonstrated evidence of the occurrence of major malformations following exposure to benzodiazepines during the first trimester of pregnancy, although incidences of cleft lip and palate were reported in certain case-control studies.
Clobazam is not recommended during pregnancy and in women of childbearing potential not using contraception.
Clobazam crosses the placenta. Animal studies have demonstrated reproductive toxicity (see section 5.3).
Women of childbearing potential should be informed of the risks and benefits of the use of clobazam during pregnancy.
Women of childbearing potential should be informed to contact her physician regarding discontinuation of the product if they are pregnant or intend to become pregnant. If clobazam treatment is continued, it should be used at the lowest effective dose.
Cases of reduced fetal movement and fetal heart rate variability have been described after administration of benzodiazepines during the second and/or third trimester of pregnancy.
If clobazam is administered during the late phase of pregnancy or during childbirth, effects on the neonate, such as respiratory depression (including respiratory distress and apnea), sedation signs, hypothermia, hypotonia, and feeding difficulties in the newborn (so-called "floppy infant syndrome") are to be expected.
Moreover, infants born to mothers who have taken benzodiazepines over longer periods during the later stages of pregnancy may have developed physical dependence and may be at risk of developing a withdrawal syndrome in the postnatal period. Appropriate monitoring of the newborn in the postnatal period is recommended.
\*\*Breast Feeding\*\*
Since benzodiazepines are found in the breast milk, benzodiazepines should not be given to breast-feeding mothers.
\*\*Fertility\*\*
There is insufficient information to assess effects of clobazam on fertility in humans (see section 5.3).4.7 Effects on ability to drive and use machines
Sedation, amnesia, impaired concentration and impaired muscular function may adversely affect the ability to drive or to use machines. If insufficient sleep duration occurs, the likelihood of impaired alertness may be increased (see also Interactions).
This medicine can impair cognitive function and can affect a patient's ability to drive safely. This class of medicine is in the list of drugs included in regulations under 5a of the Road Traffic Act 1988. When prescribing this medicine, patients should be told:
• The medicine is likely to affect your ability to drive
• Do not drive until you know how the medicine affects you
• It is an offence to drive while under the influence of this medicine
• However, you would not be committing an offence (called 'statutory defence') if:
| | | |
| --- | --- | --- |
| | o | The medicine has been prescribed to treat a medical or dental problem and |
| | o | You have taken it according to the instructions given by the prescriber and in the information provided with the medicine and |
| | o | It was not affecting your ability to drive safely. |4.8 Undesirable effects
The following CIOMS frequency rating is used, when applicable: Very common (≥ 1/10); common (≥ 1/100 to ≤ 1/10);uncommon (≥ 1/1,000 to ≤ 1/100); rare (≥ 1/10,000 to ≤ 1/1,000); very rare (≤ 1/10,000); not known (cannot be estimated from the available data).
\*Metabolism and nutrition disorders\*
Common: \*\*decreased appetite\*\*
\*Psychiatric disorders\*
Common: \*\*irritability, aggression, restlessness, depression (pre-existing depression may be unmasked), drug tolerance\*\* (especially during prolonged use), \*\*agitation\*\*
Uncommon: \*\*abnormal behaviour, confusional state, anxiety, delusion, nightmare, loss of libido\*\* (particularly with high doses or in long-term treatment and is reversible)
Not known: \*\*dependence\*\* (especially during prolonged use), \*\*initial insomnia, anger, hallucination, psychotic disorder, poor quality sleep, suicidal ideation\*\*
\*Nervous system disorders\*
Very common: \*\*somnolence\*\*, especially at the beginning of treatment and when higher doses are used
Common: \*\*sedation, dizziness, disturbance in attention, slow speech/dysarthria/ speech disorder\*\* (particularly with high doses or in long-term treatment, and are reversible), \*\*headache, tremor, ataxia\*\*
Uncommon: \*\*emotional poverty, amnesia (may be associated with abnormal behaviour),\*\* \*\*memory impairment, anterograde amnesia\*\* (in (in the normal dose range, but especially at higher dose levels)
Not known: \*\*cognitive disorder, altered state of consciousness\*\* (particularly in elderly patients, may be combined with respiratory disorders), \*\*nystagmus\*\* (particularly with high doses or in long-term treatment), \*\*gait disturbance\*\* (particularly with high doses or in longterm treatment and is reversible)
\*Eye Disorders\*
Uncommon: \*\*diplopia\*\* (particularly with high doses or in long-term treatment and is reversible)
\*Respiratory, thoracic and mediastinal disorders\*
Not known: \*\*respiratory depression respiratory failure (particularly in patients with preexisting compromised respiratory function\*\* e.g. in patients with bronchial asthma or brain damage) (see Sections 4.3 Contraindications and 4.4 Warnings and Precautions)
\*Gastrointestinal disorders\*
Common: \*\*dry mouth, nausea, constipation\*\*
\*Skin and subcutaneous tissue disorders\*
Uncommon: \*\*rash\*\*
Not known: \*\*urticaria; Steven-Johnson syndrome, toxic epidermal necrolysis (including some cases with fatal outcome);\*\*
\*Musculoskeletal and connective tissue disorders\*
Not known: \*\*muscle spasms, muscle weakness\*\*
\*General disorders and administration site conditions\*
Very common: \*\*fatigue\*\*, especially at the beginning of treatment and when higher doses are used
Not known: \*\*slow response to stimuli, hypothermia\*\*
\*Investigations\*
Uncommon: \*\*weight increased\*\* (particularly with high doses or in long-term treatment)
\*Injury poisoning and procedural complications\*
Uncommon: \*\*fall\*\* \*\*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 the Yellow Card Scheme at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.4.9 Overdose
Overdose of benzodiazepines is usually manifested by degrees of central nervous system depression ranging from drowsiness to coma. In mild cases, symptoms include drowsiness, mental confusion and lethargy, in more serious cases, symptoms may include ataxia, hypotonia, hypotension, respiratory depression, rarely coma and very rarely death. As with other benzodiazepines, overdose should not present a threat to life unless combined with other CNS depressants. The risk of a fatal outcome is increased in cases of combined poisoning with other CNS depressants (including alcohol).
In the management of overdose with any medicinal product, it is recommended that the possible involvement of multiple agents be taken into consideration.
Following overdose with oral benzodiazepines, vomiting should be induced (within one hour) if the patient is conscious, or gastric lavage undertaken with the airway protected if the patient is unconscious. If there is no advantage in emptying the stomach, activated charcoal should be given to reduce absorption. Special attention should be paid to respiratory and cardiovascular functions in intensive care.
Secondary elimination of clobazam (by forced diuresis or haemodialysis) is ineffective.
Consideration should be given to the use of flumazenil as a benzodiazepine antagonist.
- Instruction Pharmacology
- 5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Anxiolytics, Benzodiazepine derivates, ATC code: N05BA09
Clobazam is a 1,5-benzodiazepine. In single doses up to 20mg or in divided doses up to 30mg, clobazam does not affect psychomotor function, skilled performance, memory or higher mental functions.5.2 Pharmacokinetic properties
\*\*Absorption\*\*
Absorption of clobazam is virtually complete after oral administration. Approximately 85% is protein bound in man. It is metabolised by demethylation and hydroxylation. It is excreted unchanged and as metabolites in the urine (87%) and faeces.
The peak plasma level of clobazam after oral administration of [Invented name] Clobazam oral suspension 2 mg/ml was higher than that observed after administration of a reference 10 mg tablet in a single dose, randomised, crossover bioequivalence study (mean Cmax 267.5 ± 64.5 ng/ml and 220.4 ± 49.9 ng/ml, respectively).
Concomitant intake of alcohol can increase the bioavailability of clobazam by 50%.
\*\*Distribution\*\*
After a single dose of 20 mg clobazam, marked inter individual variability in maximum plasma concentrations (222 to 709 ng/ml) was observed after 0.25 to 4 hours. Clobazam is lipophilic and distributes rapidly throughout the body. Based on a population pharmacokinetic analysis, the apparent volume of distribution at steady-state was approximately 102 L, and is concentration independent over the therapeutic range. Approximately 80 – 90% of clobazam is bound to plasma protein.
Clobazam accumulates approximately 2-3 fold to steady-state while the active metabolite N-desmethylclobazam (N-CLB) accumulates approximately 20-fold following clobazam twice daily administration. Steady state concentrations are reached within approximately 2 weeks.
\*\*Metabolism\*\*
Clobazam is rapidly and extensively metabolized in the liver. Clobazam metabolism occurs primarily by hepatic demethylation to N-desmethylclobazam (N-CLB), mediated by CYP3A4 and to a lesser extent by CYP2C19. N-CLB is an active metabolite and the main circulating metabolite found in human plasma.
N-CLB undergoes further biotransformation in the liver to form 4-hydroxy-N-desmethylclobazam, primarily mediated by CYP2C19.
CYP2C19 poor metabolisers exhibit a 5-fold higher plasma concentration of N-CLB compared to extensive metabolisers.
Clobazam is a weak CYP2D6 inhibitor. Co-administration with dextromethorphan led to increases of 90% in AUC and 59% in Cmax values for dextromethorphan.
Concomitant administration of 400 mg ketoconazole (CYP3A4 inhibitor) increased clobazam AUC by 54% with no effect on Cmax.
\*\*Elimination\*\*
Based on a population pharmacokinetic analysis, plasma elimination half-lives of clobazam and N-CLB were estimated to be 36 hours and 79 hours respectively.Clobazam is cleared mainly by hepatic metabolism with subsequent renal elimination.
In a mass balance study, approximately 80% of the administered dose was recovered in urine and about 11% in the faeces. Less than 1 % of unchanged clobazam and less than 10% of unchanged N-CLB are excreted through the kidneys.5.3 Preclinical safety data
\*\*Repeat dose toxicity\*\*
In chronic toxicity studies in rats with daily oral clobazam administration of 12-1000 mg/kg, spontaneous activity was dose-dependently reduced, whereas respiratory depression and hypothermia were observed at the high dose level. Dose-dependent sedation, somnolence, ataxia and tremor were initially evident in dogs receiving daily oral doses of 2.5-80 mg/kg clobazam, which almost completely reversed in the course of the study. Similar dose- dependent effects were noted in monkeys after daily oral administration of 2.5-20 mg/kg.
\*\*Reproduction toxicity\*\*
In reproductive toxicity studies in rats and mice clobazam was reported to be without teratogenic or fertility disturbing effect (see section 4.6).
\*\*Genotoxicity and carcinogenicity\*\*
Clobazam is not genotoxic or tumorigenic. Follicular cell adenoma was significantly increased in rats at the 100 mg/kg clobazam high dose. In contrast to other species (mouse, dog, monkey), clobazam is known to activate the thyroid gland in rats like other benzodiazepine-containing agents. No effects on human thyroid function were noted at clinically relevant doses (20-80 mg).
- Instruction Pharmaceutical Particulars
- 6.1 List of excipients
Sorbitol (E420)
Xanthan Gum (E415)
Acesulfame Potassium (E950)
Raspberry Flavour
Sodium Propyl parahydroxybenzoate (E217)
Sodium Methyl parahydroxybenzoate (E219)
Disodium Hydrogen Phosphate Dihydrate (for pH-adjustment)
Sodium Dihydrogen Phosphate Dihydrate (for pH-adjustment)
Purified Water6.2 Incompatibilities
None.6.3 Shelf life
Unopened: 2 years.
Once opened: 28 days6.4 Special precautions for storage
Do not store above 25°C. Keep the bottle in the outer carton in order to protect from light.6.5 Nature and contents of container
Amber glass bottles sealed with tamper evident, child-proof plastic screw caps.
Each pack also contains a 5ml oral syringe (polypropylene body, HDPE plunger) graduated every 0.5ml, syringe adapter (LDPE) and 30ml measuring cup (polypropylene) graduated every 5ml.
Pack sizes: 150ml.6.6 Special precautions for disposal and other handling
This product may settle during storage. Please shake the bottle thoroughly before use.
- Instruction Content
- ## Composition
Each 5 ml of suspension contains 10mg of clobazam
\*\*Excipients with known effect\*\*
Each 5 ml of suspension contains 875mg of sorbitol, 15.25mg of sodium, 10.25mg of sodium methyl parahydroxybenzoate (E219) and 1.12mg of sodium propyl parahydroxybenzoate.
For the full list of excipients, see section 6.1.
## Pharmaceutical Form
Oral Suspension
An off white viscous suspension with an odour of raspberry
## Clinical Particulars
4.1 Therapeutic indications
Clobazam is a 1,5-benzodiazepine indicated for the short-term relief (2-4 weeks) only of anxiety that is severe, disabling or subjecting the individual to unacceptable distress, occurring alone or in association with insomnia or short term psychosomatic, organic or psychotic illness. The use of clobazam to treat short-term “mild” anxiety is inappropriate and unsuitable.
Before treatment of anxiety states associated with emotional instability, it must first be determined whether the patient suffers from a depressive disorder requiring adjunctive or different treatment. Indeed, in patients with anxiety associated with depression, clobazam must be used only in conjunction with adequate concomitant treatment. Use of benzodiazepine (such as clobazam) alone, can precipitate suicide in such patients.
In patients with schizophrenic or other psychotic illnesses, use of benzodiazepines is recommended only for adjunctive, i.e. not for primary treatment.
Clobazam may be used as adjunctive therapy in epilepsy in adults or children over 2 years of age, if standard treatment with one or more anticonvulsants has failed.
Clobazam oral suspension should only be used in children from 6 month to 2 years old, under exceptional situations, where there is a clear epilepsy indication.4.2 Posology and method of administration
\*\*Posology\*\*
If low doses are required, the 5 mg/5ml strength product is a more suitable presentation. If high doses are required, the 10 mg/5 ml strength product is a more suitable presentation.
For patients who require only small doses of less than 1ml, the 150ml pack size of the 5mg/5ml strength should be used, which is provided with a 1ml oral syringe.
\*\*Treatment of anxiety\*\*
Treatment should be as short as possible. The patient must be re-assessed after a period not exceeding 4 weeks and regularly thereafter in order to evaluate the need for continued treatment, especially where the patient is free of symptoms. Generally the overall duration of treatment (i.e. including tapering-off process) must not exceed 8 to 12 weeks.
In certain cases extension beyond the maximum treatment period may be necessary; if so it should not take place without re-evaluation of the patient's status with special expertise. It is strongly recommended that prolonged periods of uninterrupted treatment be avoided, since they may lead to dependance.
\*\*Adults:\*\*
The usual anxiolytic dose for adults is 20-30 mg daily in divided doses or as a single dose given at night. Doses up to 60mg daily have been used in the treatment of adult in-patients with severe anxiety.
The lowest dose that can control symptoms should be used. After improvement of the symptoms, the dose may be reduced.
It should not be used for longer than 4 weeks.
Due regard must be paid to the possibility of interference with alertness and reaction time.
Long term chronic use as an anxiolytic is not recommended. In certain cases, extension beyond the maximum treatment period may be necessary; treatment must not be extended without re-evaluation of the patient's status using special expertise. It is strongly recommended that prolonged periods of uninterrupted treatment be avoided, since they may lead to dependence. Treatment should always be withdrawn gradually. Patients who have taken clobazam for a long time may require a longer period during which doses are reduced.
\*\*Elderly:\*\*
Doses of 10-20 mg daily in anxiety may be used in the elderly, who are more sensitive to the effects of psychoactive agents. Treatment requires low initial doses and gradual dose increments under careful observation.
\*\*Treatment of epilepsy in association with one or more other anticonvulsants\*\*
The oral suspension is suitable for any epilepsy patient in whom the clinician feels an oral suspension is preferable to clobazam tablets.
In all cases, treatment should be initiated at the lowest effective dose with gradual dose increments under careful observation.
\*\*Adults\*\*
In epilepsy a starting dose of 20-30 mg/day is recommended, increasing as necessary up to a maximum of 60 mg daily.
\*\*Elderly\*\*
Treatment requires low initial doses and gradual dose increments under careful observation.
\*\*Paediatric patients aged 6 years and above:\*\*
When prescribed for children treatment requires low initial doses and gradual dose increments under careful observation. It is recommended that normally treatment should be started at 5mg daily. A maintenance dose of 0.3 to 1mg/kg body weight daily is usually sufficient.
\*\*Paediatric population aged 2 and above:\*\*
Initial: 5 mg/day (aged 6 years and above) or 0.1 mg/kg/day for younger patients. The dose may be increased slowly by steps of 0.1 to 0.2 mg/kg/day at 7 days intervals, until the required clinical effect is achieved or side effects occur.
Maintenance dose: usually 0.3 to 1 mg/kg/day. The daily dose can be taken in divided doses or as single dose at night.
\*\*Paediatric population aged between 6 months and 2 years:\*\*
Clobazam oral suspension should only be used in children from 6 month to 2 years old, under exceptional situations, when there is a clear epilepsy indication. Use 0.1mg/kg/day and titrate upwards very slowly (increasing not more often than every 5 days) to achieve required clinical effect, in divided doses twice daily.
The patient must be re-assessed after a period not exceeding 4 weeks and regularly thereafter in order to evaluate the need for continued treatment. A break in therapy may be beneficial if drug exhaustion develops, recommencing therapy at a low dose. At the end of treatment (including in poor-responding patients), since the risk of withdrawal phenomena/rebound phenomena is greater after abrupt discontinuation of treatment, it is recommended to gradually decrease the dosage.
Patients with impairment of renal or hepatic function: Increased responsiveness and higher susceptibility to adverse effects may be present in these patients and require low initial doses and gradual dose increments under careful observation. The maximum dose should not be exceeded.
The patient should be checked regularly at the start of the treatment in order to decrease if necessary, the dose or frequency of administration to prevent overdose due to accumulation.
\*\*Method of administration\*\*
For oral use only.
Once titrated to an effective dose of clobazam, patients should remain on their treatment and care should be exercised when changing between different formulations.4.3 Contraindications
Clobazam must not be used:
• In patients with hypersensitivity to the active substance, benzodiazepines or to any of the excipients listed in section 6.1.
• In patients with any history of drug or alcohol dependence (increased risk of development of dependence).
• In patients with myasthenia gravis (risk of aggravation of muscle weakness).
• In patients with severe respiratory insufficiency (risk of deterioration).
• In patients with sleep apnoea syndrome (risk of deterioration).
• In patients with severe hepatic insufficiencies (risk of precipitating encephalopathy).
• In breast-feeding women.
• During the first trimester of pregnancy (for use during second and third trimester, see section 4.6 ).
Benzodiazepines must not be given to children without careful assessment of the need for their use. Clobazam must not be used in children between the ages of 6 months to 2 years old, other than in exceptional cases for anticonvulsant treatment where there is a compelling indication. See section 4.2 for recommended dose titration advice in these circumstances.4.4 Special warnings and precautions for use
\*\*Amnesia\*\*
Benzodiazepines may induce anterograde amnesia. The condition occurs most often several hours after ingesting the product and therefore to reduce the risk patients should ensure that they will be able to have an uninterrupted sleep of 7-8 hours (see also Undesirable Effects).
\*\*Muscle weakness\*\*
Clobazam can cause muscle weakness. Special caution is necessary if clobazam is used in patients with myasthenia gravis, spinal or cerebellar ataxia or sleep apnoea. A dose reduction may be necessary. Clobazam is contraindicated in patients with myasthenia gravis.
\*\*Depression and personality disorders\*\*
Some epidemiological studies suggest an increased incidence of suicidal ideation, suicide attempt and suicide in patients with or without depression and treated with benzodiazepines and other hypnotics, including clobazam. However, a causal relationship has not been established (see section 4.8).
\*\*Dependence\*\*
Use of benzodiazepines - including clobazam - may lead to the development of physical and psychological dependence upon these products. The risk of dependence increases with dose and duration of treatment; it is also greater in patients with a history of alcohol or drug abuse. Therefore, the duration of treatment should be as short as possible (see section 4.2 Posology).
Once physical dependence has developed, abrupt termination of treatment will be accompanied by withdrawal symptoms (or rebound phenomena).
These may consist of headaches, muscle pain, extreme anxiety, tension, restlessness, confusion and irritability. In severe cases the following symptoms may occur; derealization, depersonalization, hyperacusis, numbness and tingling of the extremities, hypersensitivity to light, noise and physical contact, hallucinations or epileptic seizures.
Rebound insomnia and anxiety: a transient syndrome whereby the symptoms that led to treatment with a benzodiazepine recur in an enhanced form, may occur on withdrawal of treatment. It may be accompanied by other reactions including mood changes, anxiety or sleep disturbances and restlessness. Since the risk of withdrawal phenomena/rebound phenomena is greater after abrupt discontinuation of treatment, it is recommended that the dosage is decreased gradually.
\*\*Serious Skin Reactions\*\*
Serious skin reactions, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), have been reported with clobazam in both children and adults during the post-marketing experience. A majority of the reported cases involved the concomitant use of other drugs, including anti-epileptic drugs that are associated with serious skin reactions.
SJS/TEN could be associated with a fatal outcome. Patients should be closely monitored for signs or symptoms of SJS/TEN, especially during the first 8 weeks of treatment. Clobazam should be immediately discontinued when SJS/TEN is suspected. If signs or symptoms suggest SJS/TEN, use of this drug should not be resumed and alternative therapy should be considered (see section 4.8).
\*\*Respiratory Depression\*\*
A lower dose is also recommended for in patients with chronic or acute severe respiratory insufficiency due to the risk of respiratory depression (respiratory functions must be monitored and a dose reduction of clobazam may be necessary).
Clobazam is contraindicated in patients with severe respiratory insufficiency (please refer to section 4.3 Contraindications).
\*\*Renal and hepatic impairment\*\*
In patients with impairment of renal or hepatic function, responsiveness to clobazam and susceptibility to adverse effects are increased, and a dose reduction may be necessary. In long-term treatment renal and hepatic function must be checked regularly.
Benzodiazepines are not indicated to treat patients with severe hepatic insufficiency as they may precipitate encephalopathy.
\*\*Elderly patients\*\*
In the elderly, due to the increased sensitivity to adverse reactions such as drowsiness, dizziness, muscle weakness, there is an increased risk of fall that may result in serious injury. A dose reduction is recommended.
\*\*Tolerance in epilepsy\*\*
Some loss of efficacy to the hypnotic effects of benzodiazepines may develop after repeated use for a few weeks.
In the treatment of epilepsy with benzodiazepines - including clobazam - consideration must be given to the possibility of a decrease in anti-convulsant efficacy (development of tolerance) in the course of treatment.
\*\*CYP2C19 poor metabolisers\*\*
In patients who are CYP2C19 poor metabolisers, levels of the active metabolite N-desmethylclobazam are expected to be increased as compared to extensive metabolisers. As this may lead to increased side effects, dosage adjustment of clobazam may be necessary (e.g. low starting dose with careful dose titration (see section 5.2).
\*\*Alcohol\*\*
It is recommended that patients abstain from drinking alcohol during treatment with clobazam (increased risk of sedation and other adverse effects) (see section 4.5).
Benzodiazepines including clobazam, should be used with extreme caution in patients with a history of alcohol or drug abuse.
\*\*Concomitant use of opioids and benzodiazepines\*\*
Concomitant use of clobazam and opioids may result in sedation, respiratory depression, coma and death. Because of these risks, concomitant prescribing of benzodiazepines such as clobazam with opioids should be reserved for patients for whom alternative treatment options are not possible. If a decision is made to prescribe clobazam concomitantly with opioids, the lowest effective dose should be used, and the duration of treatment should be as short as possible (see also general dose recommendation in section 4.2).
The patients should be followed closely for signs and symptoms of respiratory depression and sedation. In this respect, it is strongly recommended to inform patients and their caregivers (where applicable) to be aware of these symptoms (see section 4.5).
In the treatment of epilepsy with benzodiazepines - including clobazam - consideration must be given to the possibility of a decrease in anticonvulsant efficacy (development of tolerance) in the course of treatment.
\*\*Concomitant use of cannabidiol\*\*
The concomitant use of clobazam with cannabidiol-containing medicinal and non-medicinal products may result in increased exposure to N-desmethylclobazam, leading to increased incidence of somnolence and sedation. Dosage adjustment of clobazam may be necessary. Non-medicinal products containing cannabidiol must not be taken in combination with clobazam as they contain unknown quantities of cannabidiol and are of variable quality (see sections 4.5 and 5.2).
\*\*Excipient in the formulation\*\*
Clobazam Oral Suspension contains sorbitol. Patients with rare hereditary problems of fructose intolerance should not take this medicine.
The medicine also contains sodium methyl and propyl parahydroxybenzoates which may cause allergic reactions. The signs may include a rash, swallowing or breathing problems and swelling of the lips, face, throat or tongue.
Sodium - contains 3.05 mg/ml. this should be taken into account by patients on a low sodium diet.
\*\*Risks from concomitant use of opioids and benzodiazepines\*\*
Concomitant use of Clobazam and opioids may result in sedation, respiratory depression, coma and death. Because of these risks, concomitant prescribing of sedative medicines such as benzodiazepines or related drugs such as Clobazam with opioids should be reserved for patients for whom alternative treatment options are not possible.
If a decision is made to prescribe Clobazam concomitantly with opioids, the lowest effective dose should be used, and the duration of treatment should be as short as possible (see also general dose recommendation in section 4.2). The patients should be followed closely for signs and symptoms of respiratory depression and sedation. In this respect, it is strongly recommended to inform patients and their environment to be aware of these symptoms (see section 4.5).
\*\*Duration of treatment\*\*
The duration of treatment should be as short as possible (see Posology). Extension beyond these periods should not take place without revaluation of the situation.
It may be useful to inform the patient when treatment is started that it will be of limited duration and to explain precisely how the dosage will be progressively decreased. Moreover it is important that the patient should be aware of the possibility of rebound phenomena, thereby minimising anxiety over such symptoms should they occur while the medicinal product is being discontinued.
There are indications that, in the case of benzodiazepines with a short duration of action, withdrawal phenomena can become manifest within the dosage interval, especially when the dosage is high. When benzodiazepines with a long duration of action are being used (for example Frisium) it is important to warn against changing to a benzodiazepine with a short duration of action, as withdrawal symptoms may develop.
\*\*Psychiatric and 'paradoxical' reactions\*\*
Reactions like restlessness, agitation, irritability, aggressiveness, delusion, rages, nightmares, hallucinations, psychoses, inappropriate behaviour and other adverse behavioural effects are known to occur when using benzodiazepines. Should this occur, use of the drug should be discontinued.
They are more likely to occur in children and the elderly.
Benzodiazepines are not recommended for the primary treatment of psychotic illness.
\*\*Specific patient groups\*\*
Benzodiazepines must not be given to children without careful assessment of the need for their use. Clobazam must not be used in children between the ages of 6 months and 3 years, other than in exceptional cases for anticonvulsants treatment where there is a compelling indication.
The duration of treatment must be kept to a minimum.4.5 Interaction with other medicinal products and other forms of interaction
\*\*Alcohol\*\*
Concomitant consumption of alcohol can increase the bioavailability of clobazam by 50% (see section 5.2) and therefore increase the effects of clobazam e.g. sedation (see section 4.5).
\*\*Central nervous system depressant drugs\*\*
Especially when clobazam is administered at higher doses, an enhancement of the central depressive effect may occur in cases of concomitant use with antipsychotics , hypnotics, anxiolytics/sedatives, antidepressant agents, narcotic analgesics, anti-convulsant drugs, anaesthetics and sedative antihistamines. Special caution is also necessary when clobazam is administered in cases of intoxication with such substances or with lithium.
\*\*Opioids\*\*
The concomitant use of sedative medicines such as benzodiazepines or related drugs such as Clobazam with opioids increases the risk of sedation, respiratory depression, coma and death because of additive CNS depressant effect. The dosage and duration of concomitant use should be limited (see section 4.4).
\*\*Anti-convulsants\*\*
Addition of clobazam to established anti-convulsant medication (e.g phenytoin, valproic acid) may cause a change in plasma levels of these drugs. If used as an adjuvant in epilepsy the dosage of clobazam should be determined by monitoring the EEG and the plasma levels of the other drugs checked.
Phenytoin and carbamazepine may cause an increase in the metabolic conversion of clobazam to the active metabolite N-desmethylclobazam, , which may result in adverse reactions.
Stiripentol increases plasma levels of clobazam and its active metabolite Ndesmethylclobazam, through inhibition of CYP3A and CYP2C19. Monitoring of blood levels is recommended, prior to initiation of stiripentol, and then once new steady-state concentration has been reached, i.e. after 2 weeks approximately.
\*\*Muscle relaxants\*\*
The effects of muscle relaxants, analgesics and nitrous oxide may be enhanced.
\*\*Narcotic analgesics\*\*
If clobazam is used concomitantly with narcotic analgesics, possible euphoria may be enhanced; this may lead to increased psychological dependence.
\*\*MAOIs\*\*
Concurrent treatment with drugs that inhibit the cytochrome P-450 enzyme (mono- oxygenase) system (e.g. cimetidine) may enhance and prolong the effect of clobazam.
\*\*CYP2C19 inhibitors\*\*
Strong and moderate inhibitors of CYP2C19 may result in increased exposure to N-desmethylclobazam (N-CLB), the active metabolite of clobazam. Dosage adjustment of clobazam may be necessary when co-administered with strong (e.g. fluconazole, fluvoxamine, ticlopidine) or moderate (e.g. omeprazole) CYP2C19 inhibitors (see Section 5.2).
\*\*CYP2D6 substrates\*\*
Clobazam is a weak CYP2D6 inhibitor. Dose adjustment of drugs metabolized by CYP2D6 (e.g. dextromethorphan, pimozide, paroxetine, nebivolol) may be necessary.
\*\*Cannabidiol\*\*
When cannabidiol and clobazam are co-administered, bi-directional PK interactions occur. Based on a healthy volunteer study, elevated levels (3- to 4-fold) of N-desmethylclobazam (an active metabolite of clobazam) can occur when combined with cannabidiol, likely mediated by CYP2C19 inhibition. Increased systemic levels of these active substances may lead to enhanced pharmacological effects and to an increase in adverse drug reactions. Concomitant use of cannabidiol and clobazam increases the incidence of somnolence and sedation. Reduction in dose of clobazam should be considered if somnolence or sedation are experienced when clobazam is co-administered with cannabidiol.4.6 Fertility, pregnancy and lactation
\*\*Pregnancy\*\*
There are limited amount of data from the use of clobazam in pregnant women.
Nevertheless, a large amount of data collected from cohort studies has not demonstrated evidence of the occurrence of major malformations following exposure to benzodiazepines during the first trimester of pregnancy, although incidences of cleft lip and palate were reported in certain case-control studies.
Clobazam is not recommended during pregnancy and in women of childbearing potential not using contraception.
Clobazam crosses the placenta. Animal studies have demonstrated reproductive toxicity (see section 5.3).
Women of childbearing potential should be informed of the risks and benefits of the use of clobazam during pregnancy.
Women of childbearing potential should be informed to contact her physician regarding discontinuation of the product if they are pregnant or intend to become pregnant. If clobazam treatment is continued, it should be used at the lowest effective dose.
Cases of reduced fetal movement and fetal heart rate variability have been described after administration of benzodiazepines during the second and/or third trimester of pregnancy.
If clobazam is administered during the late phase of pregnancy or during childbirth, effects on the neonate, such as respiratory depression (including respiratory distress and apnea), sedation signs, hypothermia, hypotonia, and feeding difficulties in the newborn (so-called "floppy infant syndrome") are to be expected.
Moreover, infants born to mothers who have taken benzodiazepines over longer periods during the later stages of pregnancy may have developed physical dependence and may be at risk of developing a withdrawal syndrome in the postnatal period. Appropriate monitoring of the newborn in the postnatal period is recommended.
\*\*Breast Feeding\*\*
Since benzodiazepines are found in the breast milk, benzodiazepines should not be given to breast-feeding mothers.
\*\*Fertility\*\*
There is insufficient information to assess effects of clobazam on fertility in humans (see section 5.3).4.7 Effects on ability to drive and use machines
Sedation, amnesia, impaired concentration and impaired muscular function may adversely affect the ability to drive or to use machines. If insufficient sleep duration occurs, the likelihood of impaired alertness may be increased (see also Interactions).
This medicine can impair cognitive function and can affect a patient's ability to drive safely. This class of medicine is in the list of drugs included in regulations under 5a of the Road Traffic Act 1988. When prescribing this medicine, patients should be told:
• The medicine is likely to affect your ability to drive
• Do not drive until you know how the medicine affects you
• It is an offence to drive while under the influence of this medicine
• However, you would not be committing an offence (called 'statutory defence') if:
| | | |
| --- | --- | --- |
| | o | The medicine has been prescribed to treat a medical or dental problem and |
| | o | You have taken it according to the instructions given by the prescriber and in the information provided with the medicine and |
| | o | It was not affecting your ability to drive safely. |4.8 Undesirable effects
The following CIOMS frequency rating is used, when applicable: Very common (≥ 1/10); common (≥ 1/100 to ≤ 1/10);uncommon (≥ 1/1,000 to ≤ 1/100); rare (≥ 1/10,000 to ≤ 1/1,000); very rare (≤ 1/10,000); not known (cannot be estimated from the available data).
\*Metabolism and nutrition disorders\*
Common: \*\*decreased appetite\*\*
\*Psychiatric disorders\*
Common: \*\*irritability, aggression, restlessness, depression (pre-existing depression may be unmasked), drug tolerance\*\* (especially during prolonged use), \*\*agitation\*\*
Uncommon: \*\*abnormal behaviour, confusional state, anxiety, delusion, nightmare, loss of libido\*\* (particularly with high doses or in long-term treatment and is reversible)
Not known: \*\*dependence\*\* (especially during prolonged use), \*\*initial insomnia, anger, hallucination, psychotic disorder, poor quality sleep, suicidal ideation\*\*
\*Nervous system disorders\*
Very common: \*\*somnolence\*\*, especially at the beginning of treatment and when higher doses are used
Common: \*\*sedation, dizziness, disturbance in attention, slow speech/dysarthria/ speech disorder\*\* (particularly with high doses or in long-term treatment, and are reversible), \*\*headache, tremor, ataxia\*\*
Uncommon: \*\*emotional poverty, amnesia (may be associated with abnormal behaviour),\*\* \*\*memory impairment, anterograde amnesia\*\* (in (in the normal dose range, but especially at higher dose levels)
Not known: \*\*cognitive disorder, altered state of consciousness\*\* (particularly in elderly patients, may be combined with respiratory disorders), \*\*nystagmus\*\* (particularly with high doses or in long-term treatment), \*\*gait disturbance\*\* (particularly with high doses or in longterm treatment and is reversible)
\*Eye Disorders\*
Uncommon: \*\*diplopia\*\* (particularly with high doses or in long-term treatment and is reversible)
\*Respiratory, thoracic and mediastinal disorders\*
Not known: \*\*respiratory depression respiratory failure (particularly in patients with preexisting compromised respiratory function\*\* e.g. in patients with bronchial asthma or brain damage) (see Sections 4.3 Contraindications and 4.4 Warnings and Precautions)
\*Gastrointestinal disorders\*
Common: \*\*dry mouth, nausea, constipation\*\*
\*Skin and subcutaneous tissue disorders\*
Uncommon: \*\*rash\*\*
Not known: \*\*urticaria; Steven-Johnson syndrome, toxic epidermal necrolysis (including some cases with fatal outcome);\*\*
\*Musculoskeletal and connective tissue disorders\*
Not known: \*\*muscle spasms, muscle weakness\*\*
\*General disorders and administration site conditions\*
Very common: \*\*fatigue\*\*, especially at the beginning of treatment and when higher doses are used
Not known: \*\*slow response to stimuli, hypothermia\*\*
\*Investigations\*
Uncommon: \*\*weight increased\*\* (particularly with high doses or in long-term treatment)
\*Injury poisoning and procedural complications\*
Uncommon: \*\*fall\*\* \*\*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 the Yellow Card Scheme at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.4.9 Overdose
Overdose of benzodiazepines is usually manifested by degrees of central nervous system depression ranging from drowsiness to coma. In mild cases, symptoms include drowsiness, mental confusion and lethargy, in more serious cases, symptoms may include ataxia, hypotonia, hypotension, respiratory depression, rarely coma and very rarely death. As with other benzodiazepines, overdose should not present a threat to life unless combined with other CNS depressants. The risk of a fatal outcome is increased in cases of combined poisoning with other CNS depressants (including alcohol).
In the management of overdose with any medicinal product, it is recommended that the possible involvement of multiple agents be taken into consideration.
Following overdose with oral benzodiazepines, vomiting should be induced (within one hour) if the patient is conscious, or gastric lavage undertaken with the airway protected if the patient is unconscious. If there is no advantage in emptying the stomach, activated charcoal should be given to reduce absorption. Special attention should be paid to respiratory and cardiovascular functions in intensive care.
Secondary elimination of clobazam (by forced diuresis or haemodialysis) is ineffective.
Consideration should be given to the use of flumazenil as a benzodiazepine antagonist.
## Pharmacological Properties
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Anxiolytics, Benzodiazepine derivates, ATC code: N05BA09
Clobazam is a 1,5-benzodiazepine. In single doses up to 20mg or in divided doses up to 30mg, clobazam does not affect psychomotor function, skilled performance, memory or higher mental functions.5.2 Pharmacokinetic properties
\*\*Absorption\*\*
Absorption of clobazam is virtually complete after oral administration. Approximately 85% is protein bound in man. It is metabolised by demethylation and hydroxylation. It is excreted unchanged and as metabolites in the urine (87%) and faeces.
The peak plasma level of clobazam after oral administration of [Invented name] Clobazam oral suspension 2 mg/ml was higher than that observed after administration of a reference 10 mg tablet in a single dose, randomised, crossover bioequivalence study (mean Cmax 267.5 ± 64.5 ng/ml and 220.4 ± 49.9 ng/ml, respectively).
Concomitant intake of alcohol can increase the bioavailability of clobazam by 50%.
\*\*Distribution\*\*
After a single dose of 20 mg clobazam, marked inter individual variability in maximum plasma concentrations (222 to 709 ng/ml) was observed after 0.25 to 4 hours. Clobazam is lipophilic and distributes rapidly throughout the body. Based on a population pharmacokinetic analysis, the apparent volume of distribution at steady-state was approximately 102 L, and is concentration independent over the therapeutic range. Approximately 80 – 90% of clobazam is bound to plasma protein.
Clobazam accumulates approximately 2-3 fold to steady-state while the active metabolite N-desmethylclobazam (N-CLB) accumulates approximately 20-fold following clobazam twice daily administration. Steady state concentrations are reached within approximately 2 weeks.
\*\*Metabolism\*\*
Clobazam is rapidly and extensively metabolized in the liver. Clobazam metabolism occurs primarily by hepatic demethylation to N-desmethylclobazam (N-CLB), mediated by CYP3A4 and to a lesser extent by CYP2C19. N-CLB is an active metabolite and the main circulating metabolite found in human plasma.
N-CLB undergoes further biotransformation in the liver to form 4-hydroxy-N-desmethylclobazam, primarily mediated by CYP2C19.
CYP2C19 poor metabolisers exhibit a 5-fold higher plasma concentration of N-CLB compared to extensive metabolisers.
Clobazam is a weak CYP2D6 inhibitor. Co-administration with dextromethorphan led to increases of 90% in AUC and 59% in Cmax values for dextromethorphan.
Concomitant administration of 400 mg ketoconazole (CYP3A4 inhibitor) increased clobazam AUC by 54% with no effect on Cmax.
\*\*Elimination\*\*
Based on a population pharmacokinetic analysis, plasma elimination half-lives of clobazam and N-CLB were estimated to be 36 hours and 79 hours respectively.Clobazam is cleared mainly by hepatic metabolism with subsequent renal elimination.
In a mass balance study, approximately 80% of the administered dose was recovered in urine and about 11% in the faeces. Less than 1 % of unchanged clobazam and less than 10% of unchanged N-CLB are excreted through the kidneys.5.3 Preclinical safety data
\*\*Repeat dose toxicity\*\*
In chronic toxicity studies in rats with daily oral clobazam administration of 12-1000 mg/kg, spontaneous activity was dose-dependently reduced, whereas respiratory depression and hypothermia were observed at the high dose level. Dose-dependent sedation, somnolence, ataxia and tremor were initially evident in dogs receiving daily oral doses of 2.5-80 mg/kg clobazam, which almost completely reversed in the course of the study. Similar dose- dependent effects were noted in monkeys after daily oral administration of 2.5-20 mg/kg.
\*\*Reproduction toxicity\*\*
In reproductive toxicity studies in rats and mice clobazam was reported to be without teratogenic or fertility disturbing effect (see section 4.6).
\*\*Genotoxicity and carcinogenicity\*\*
Clobazam is not genotoxic or tumorigenic. Follicular cell adenoma was significantly increased in rats at the 100 mg/kg clobazam high dose. In contrast to other species (mouse, dog, monkey), clobazam is known to activate the thyroid gland in rats like other benzodiazepine-containing agents. No effects on human thyroid function were noted at clinically relevant doses (20-80 mg).
## Pharmaceutical Particulars
6.1 List of excipients
Sorbitol (E420)
Xanthan Gum (E415)
Acesulfame Potassium (E950)
Raspberry Flavour
Sodium Propyl parahydroxybenzoate (E217)
Sodium Methyl parahydroxybenzoate (E219)
Disodium Hydrogen Phosphate Dihydrate (for pH-adjustment)
Sodium Dihydrogen Phosphate Dihydrate (for pH-adjustment)
Purified Water6.2 Incompatibilities
None.6.3 Shelf life
Unopened: 2 years.
Once opened: 28 days6.4 Special precautions for storage
Do not store above 25°C. Keep the bottle in the outer carton in order to protect from light.6.5 Nature and contents of container
Amber glass bottles sealed with tamper evident, child-proof plastic screw caps.
Each pack also contains a 5ml oral syringe (polypropylene body, HDPE plunger) graduated every 0.5ml, syringe adapter (LDPE) and 30ml measuring cup (polypropylene) graduated every 5ml.
Pack sizes: 150ml.6.6 Special precautions for disposal and other handling
This product may settle during storage. Please shake the bottle thoroughly before use.
