- Approval Id
- cdeee2fcc5ee630a
- Drug Approval Emc Name
- Ciproxin 250 mg/5 mL granules and solvent for oral suspension
- Drug Name
- Ciproxin 250 mg/5 mL granules and solvent for oral suspension
- Company Name
- Bayer plc
- Company Address
- 400 South Oak Way, Reading, Berkshire, RG2 6AD
- Company Website
- http://www.bayer.co.uk
- Company Telephone
- +44 (0)118 206 3000
- Company Medical Info Email
- medical.information@bayer.co.uk
- Atc Code
- J01MA02
- Legal Category
- Prescription only medicine
- Authorisation Holder
- Bayer Plc
400 South Oak Way
Reading, RG2 6AD
- Authorisation Number
- PL 00010/0211
- Authorisation Date
- 19 April 1996/5 January 2006.
- Instruction Authorisation Holder
- Bayer Plc
400 South Oak Way
Reading, RG2 6AD
- Instruction Authorisation Number
- PL 00010/0211
- Instruction Authorisation Date
- 19 April 1996/5 January 2006.
- Instruction Composition
- 5 mL suspension after reconstitution (1 measuring spoon) contains 250 mg ciprofloxacin.
2.5 mL suspension after reconstitution (1/2 measuring spoon) contains 125 mg ciprofloxacin.
Excipients with known effect: benzyl alcohol, sucrose.
One measuring spoon (5 mL of suspension) contains approx. 1.4 g of sucrose.
For the full list of excipients, see section 6.1.
- Instruction Dosage Form
- Granules and solvent for oral suspension.
Appearance before reconstitution:
Granules: white to slightly yellowish granules
Solvent: white to slightly yellowish suspension
- Instruction Clinical Particulars
- 4.1 Therapeutic indications
Because of the risk of prolonged, disabling and potentially irreversible serious adverse drug reactions (see section 4.4 and section 4.8) this product must only be prescribed when other antibiotics that are commonly recommended for the infection are inappropriate. This applies to all indications listed below. Situations where other antibiotics are considered to be inappropriate are where:
• there is resistance to other first-line antibiotics recommended for the infection;
• other first-line antibiotics are contraindicated in an individual patient;
• other first-line antibiotics have caused side effects requiring treatment to be stopped;
• treatment with other first-line antibiotics has failed.
The Ciproxin 250 mg/5 mL oral suspension is indicated for the treatment of the following infections (see sections 4.4 and 5.1). Special attention should be paid to available information on resistance to ciprofloxacin before commencing therapy.
Consideration should be given to official guidance on the appropriate use of antibacterial agents.
\*\*Adults\*\*
• Lower respiratory tract infections due to Gram-negative bacteria
- exacerbation of chronic obstructive pulmonary disease.
- broncho-pulmonary infections in cystic fibrosis or in bronchiectasis
- pneumonia
• Chronic suppurative otitis media
• Acute exacerbation of chronic sinusitis especially if these are caused by Gram-negative bacteria
• Urinary tract infections
- Uncomplicated acute cystitis.
- Acute pyelonephritis
- Complicated urinary tract infections
- Bacterial prostatitis
• Genital tract infections
- gonococcal uretritis and cervicitis due to susceptible \*Neisseria gonorrhoeae\*
- epididymo-orchitis including cases due to susceptible \*Neisseria gonorrhoeae\*
- pelvic inflammatory disease including cases due to susceptible \*Neisseria gonorrhoeae\*
• Infections of the gastro-intestinal tract (e.g. travellers' diarrhoea)
• Intra-abdominal infections
• Infections of the skin and soft tissue caused by Gram-negative bacteria
• Malignant external otitis
• Infections of the bones and joints
• Prophylaxis of invasive infections due to \*Neisseria meningitidis\*
• Inhalation anthrax (post-exposure prophylaxis and curative treatment)
Ciprofloxacin may be used in the management of neutropenic patients with fever that is suspected to be due to a bacterial infection.
\*\*Children and adolescents\*\*
• Broncho-pulmonary infections due to \*Pseudomonas aeruginosa\* in patients with cystic fibrosis
• Complicated urinary tract infections and acute pyelonephritis
• Inhalation anthrax (post-exposure prophylaxis and curative treatment)
Ciprofloxacin may also be used to treat severe infections in children and adolescents when this is considered to be necessary.
Treatment should be initiated only by physicians who are experienced in the treatment of cystic fibrosis and/or severe infections in children and adolescents (see sections 4.4 and 5.1).4.2 Posology and method of administration
\*\*Posology\*\*
The dosage is determined by the indication, the severity and the site of the infection, the susceptibility to ciprofloxacin of the causative organism(s), the renal function of the patient and, in children and adolescents the body weight.
The duration of treatment depends on the severity of the illness and on the clinical and bacteriological course.
Treatment of infections due to certain bacteria (e.g. \*Pseudomonas aeruginosa\*, \*Acinetobacter\* or \*Staphylococci\*) may require higher ciprofloxacin doses and co-administration with other appropriate antibacterial agents.
Treatment of some infections (e.g. pelvic inflammatory disease, intra-abdominal infections, infections in neutropenic patients and infections of bones and joints) may require co-administration with other appropriate antibacterial agents depending on the pathogens involved.
\*\*\*Adults\*\*\*
| | | | | |
| --- | --- | --- | --- | --- |
| \*\*Indications\*\* | | \*\*Daily dose in mg\*\* | \*\*Daily dose in mL\*\* \*\*(Number of 5-mL measuring spoonfuls)\*\* | \*\*Total duration of treatment (potentially including initial parenteral treatment with ciprofloxacin)\*\* |
| Infections of the lower respiratory tract | | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15 mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | 7 to 14 days |
| Infections of the upper respiratory tract | Acute exacerbation of chronic sinusitis | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15 mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | 7 to 14 days |
| Chronic suppurative otitis media | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15 mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | 7 to 14 days |
| Malignant external otitis | 750 mg twice daily | 15 mL twice daily (three 5-mL measuring spoonfuls twice daily) | 28 days up to 3 months |
| Urinary tract infections (see section 4.4) | Uncomplicated acute cystitis | 250 mg twice daily to 500 mg twice daily | 5-mL twice daily to 10 mL twice daily (one 5-mL measuring spoonful twice daily up to two 5-mL measuring spoonfuls twice daily) | 3 days |
| In pre-menopausal women, 500 mg single dose may be used corresponding to 10 mL single dose = two 5-mL measuring spoonfuls as a single dose | | |
| Complicated cystitis, Acute pyelonephritis | 500 mg twice daily | 10 mL twice daily (two 5-mL measuring spoonfuls twice daily) | 7 days |
| Complicated pyelonephritis | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15-mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | at least 10 days, it can be continued for longer than 21 days in some specific circumstances (such as abscesses) |
| Bacterial prostatitis | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15-mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | 2 to 4 weeks (acute) to 4 to 6 weeks (chronic) |
| Genital tract infections | Gonococcal uretritis and cervicitis due to susceptible \*Neisseria gonorrhoeae\* | 500 mg as a single dose | 10 mL as a single dose corresponding to two 5-mL measuring spoonfuls as a single dose | 1 day (single dose) |
| Epididymo-orchitis and pelvic inflammatory diseases including cases due to susceptible \*Neisseria gonorrhoeae\* | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15-mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | at least 14 days |
| Infections of the gastro-intestinal tract and intra-abdominal infections | Diarrhoea caused by bacterial pathogens including \*Shigella\* spp. other than \*Shigella\* \*dysenteriae\* type 1 and empirical treatment of severe travellers' diarrhoea | 500 mg twice daily | 10 mL twice daily (two 5-mL measuring spoonfuls twice daily) | 1 day |
| Diarrhoea caused by \*Shigella\* \*dysenteriae\* type 1 | 500 mg twice daily | 10 mL twice daily (two 5-mL measuring spoonfuls twice daily) | 5 days |
| Diarrhoea caused by \*Vibrio\* \*cholerae\* | 500 mg twice daily | 10 mL twice daily (two 5-mL measuring spoonfuls twice daily) | 3 days |
| Typhoid fever | 500 mg twice daily | 10 mL twice daily (two 5-mL measuring spoonfuls twice daily) | 7 days |
| Intra-abdominal infections due to Gram-negative bacteria | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15-mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | 5 to 14 days |
| Infections of the skin and soft tissue caused by Gram-negative bacteria | | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15-mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | 7 to 14 days |
| Bone and joint infections | | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15-mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | max. of 3 months |
| Neutropenic patients with fever that is suspected to be due to a bacterial infection. Ciprofloxacin should be co-administered with appropriate antibacterial agent(s) in accordance to official guidance. | | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15-mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | Therapy should be continued over the entire period of neutropenia |
| Prophylaxis of invasive infections due to \*Neisseria meningitidis\* | | 500 mg as a single dose | 10 mL as a single dose corresponding to two 5-mL measuring spoonfuls as a single dose | 1 day (single dose) |
| Inhalation anthrax post-exposure prophylaxis and curative treatment for persons able to receive treatment by oral route when clinically appropriate. Drug administration should begin as soon as possible after suspected or confirmed exposure. | | 500 mg twice daily | 10 mL twice daily (two 5-mL measuring spoonfuls twice daily) | 60 days from the confirmation of \*Bacillus anthracis\* exposure |
\*\*\*Paediatric population\*\*\*
| | | |
| --- | --- | --- |
| \*\*Indications\*\* | \*\*Daily dose in mg and in mL\*\* For practical guidance on the number of measuring spoonfuls, refer to table A below | \*\*Total duration of treatment (potentially including initial parenteral treatment with ciprofloxacin)\*\* |
| Cystic fibrosis | 20 mg/kg body weight twice daily with a maximum of 750 mg per dose, corresponding to a 0.4 mL/kg body weight twice daily with a maximum of 15-mL per each of the two daily administrations for the 250mg/5mL suspension | 10 to 14 days |
| Complicated urinary tract infections and acute pyelonephritis | 10 mg/kg body weight twice daily to 20 mg/kg body weight twice daily with a maximum of 750 mg per dose, corresponding to a 0.2 mL/kg body weight twice daily to 0.4 mL/kg body weight twice daily with a maximum of 15-mL per each of the two daily administrations for the 250mg/5mL suspension | 10 to 21 days |
| Inhalation anthrax post-exposure prophylaxis and curative treatment for persons able to receive treatment by oral route when clinically appropriate. Drug administration should begin as soon as possible after suspected or confirmed exposure. | 10 mg/kg body weight twice daily to 15 mg/kg body weight twice daily with a maximum of 500 mg per dose, corresponding to a 0.2 mL/kg body weight twice daily to 0.3 mL/kg body weight twice daily with a maximum of 10 mL per each of the two daily administrations for the 250mg/5mL suspension | 60 days from the confirmation of \*Bacillus anthracis\* exposure |
| Other severe infections | 20 mg/kg body weight twice daily with a maximum of 750 mg per dose, corresponding to a 0.4 mL/kg body weight twice daily with a maximum of 15-mL per each of the two daily administrations for the 250mg/5mL suspension | According to the type of infections |
\*\*Table A: 250 mg/5 mL oral suspension – Practical guidance on the number of measuring spoonfuls to be administered twice daily (every 12 hours)\*\*
| | | |
| --- | --- | --- |
| \*\*250 mg/5 mL oral suspension\*\* ½ spoon = 125 mg ; 1 spoon = 250 mg ; 1 spoon + ½ spoon = 375 mg ; 2 spoons = 500 mg ; 2 spoons + ½ spoon = 625 mg ; 3 spoons = 750 mg (max dose) | | |
| \*\*Body weight (kg)\*\* | \*\*Practical guidance for each of the two daily administrations of Ciproxin oral suspension per recommended dose in mg/kg bodyweight and indications as stated above\*\* | |
| | \*\*10 mg/kg\*\* | \*\*20 mg/kg\*\* |
| 9-10 kg | ½ spoon | 1 spoon\\* |
| 11-15 kg | ½ spoon | 1 spoon |
| 16-20 kg | 1 spoon | 1 spoon + ½ spoon |
| 21-25 kg | 1 spoon | 2 spoons |
| 26-28 kg | 1 spoon | 2 spoons + ½ spoon |
| 29-31 kg | 1 spoon + ½ spoon | 2 spoons + ½ spoon |
| 32-40 kg | 1 spoon + ½ spoon | 3 spoons |
| 41-51 kg | 2 spoons | 3 spoons |
| 52-61 kg | 2 spoons + ½ spoon | 3 spoons |
| 62 kg and above | 3 spoons | 3 spoons |
| \\* The administration of number of measuring spoonfuls leads to an actual dose more than 20 % above the recommended maximum dose per bodyweight | | |
\*\*\*Elderly patients\*\*\*
Elderly patients should receive a dose selected according to the severity of the infection and the patient's creatinine clearance.
\*\*\*Patients with renal and hepatic impairment\*\*\*
Recommended starting and maintenance doses for patients with impaired renal function:
| | | |
| --- | --- | --- |
| \*\*Creatinine Clearance [mL/min/ 1.73 m²]\*\* | \*\*Serum Creatinine [µmol/L]\*\* | \*\*Oral Dose [mg]\*\* |
| > 60 | < 124 | See Usual Dosage. |
| 30-60 | 124 to 168 | 250-500 mg every 12 h |
| < 30 | > 169 | 250-500 mg every 24 h |
| Patients on haemodialysis | > 169 | 250-500 mg every 24 h (after dialysis) |
| Patients on peritoneal dialysis | > 169 | 250-500 mg every 24 h |
In patients with impaired liver function no dose adjustment is required.
Dosing in children with impaired renal and/or hepatic function has not been studied.
\*\*Method of administration\*\*
Oral suspension can be taken independent of mealtimes.
If a dose is missed, it should be taken anytime but not later than 6 hours prior to the next scheduled dose. If less than 6 hours remain before the next dose, the missed dose should not be taken and treatment should be continued as prescribed with the next scheduled dose. Double doses should not be taken to compensate for a missed dose.
If taken on an empty stomach, the active substance is absorbed more rapidly.
Ciprofloxacin oral suspension can be taken \*\*during meals\*\* containing dairy products or mineral-fortified drinks. However,ciprofloxacin oral suspension should not be administered concurrently with dairy products (e.g. milk, yoghurt) or mineral-fortified fruit juice (e.g. calcium-fortified orange juice) when these products or drinks are \*\*taken alone\*\* outside meals. Nevertheless ciprofloxacin oral suspension could be administered either 1-2 hours before or at least 4 hours after dairy products or mineral-fortified drinks when these products and drinks are taken alone outside meals, such as recommended for drugs containing calcium (see section 4.5, paragraph Food and Dairy Products).
In severe cases or if the patient is unable to take oral suspension (e.g. patients on enteral nutrition), it is recommended to commence therapy with intravenous ciprofloxacin until a switch to oral administration is possible.
For instructions on reconstitution of the product before administration, see section 6.6.
\*\*Appearance of the reconstituted product:\*\*
The reconstituted product is a white to slightly yellowish suspension with strawberry odour. Occasionally the suspension may contain yellow-orange droplets and globular particles.
½ measuring spoonful (approx 2.5 mL suspension) provides approx. 125 mg ciprofloxacin.
1 measuring spoonful (approx 5.0 mL suspension) provides approx. 250 mg ciprofloxacin.
Always use the graduated measuring spoon to obtain the dose for administering the suspension.
No additions should be made to the mixed final ciprofloxacin suspension.4.3 Contraindications
• Hypersensitivity to the active substance, to other quinolones or to any of the excipients listed in section 6.1.
• Concomitant administration of ciprofloxacin and tizanidine (see section 4.5).4.4 Special warnings and precautions for use
The use of Ciprofloxacin should be avoided in patients who have experienced serious adverse reactions in the past when using quinolone or fluoroquinolone containing products (see section 4.8). Treatment of these patients with Ciprofloxacin should only be initiated in the absence of alternative treatment options and after careful benefit/risk assessment (see also section 4.3).
\*\*Prolonged, disabling and potentially irreversible serious adverse drug reactions\*\*
Cases of prolonged (continuing for months or years), disabling and potentially irreversible serious adverse drug reactions affecting different, sometimes multiple, body systems (including musculoskeletal, nervous, psychiatric and senses) have been reported in patients receiving quinolones and fluoroquinolones irrespective of their age and pre-existing risk factors. There are no pharmacological treatments established to be effective treatments of the symptoms of long lasting or disabling side effects associated with fluoroquinolones. Ciprofloxacin should be discontinued immediately at the first signs or symptoms of any serious adverse reaction and patients should be advised to contact their prescriber for advice, so that symptoms can be appropriately investigated and to avoid further exposure which could potentially worsen adverse reactions.
\*\*Severe infections and mixed infections with Gram-positive and anaerobic pathogens\*\*
Ciprofloxacin monotherapy is not suited for treatment of severe infections and infections that might be due to Gram-positive or anaerobic pathogens. In such infections ciprofloxacin must be co-administered with other appropriate antibacterial agents.
\*\*Streptococcal Infections (including Streptococcus pneumoniae)\*\*
Ciprofloxacin is not recommended for the treatment of streptococcal infections due to inadequate efficacy.
\*\*Genital tract infections\*\*
Gonococcal uretritis, cervicitis, epididymo-orchitis and pelvic inflammatory diseases may be caused by fluoroquinolone-resistant \*Neisseria gonorrhoeae\* isolates.
Therefore, ciprofloxacin should be administered for the treatment of gonococcal uretritis or cervicitis only if ciprofloxacin-resistant \*Neisseria gonorrhoeae\* can be excluded.
For epididymo-orchitis and pelvic inflammatory diseases, empirical ciprofloxacin should only be considered in combination with another appropriate antibacterial agent (e.g. a cephalosporin) unless ciprofloxacin-resistant \*Neisseria gonorrhoeae\* can be excluded. If clinical improvement is not achieved after 3 days of treatment, the therapy should be reconsidered.
\*\*Urinary tract infections\*\*
Resistance to fluoroquinolones of \*Escherichia coli\* – the most common pathogen involved in urinary tract infections – varies across the European Union. Prescribers are advised to take into account the local prevalence of resistance in \*Escherichia coli\* to fluoroquinolones.
The single dose of ciprofloxacin that may be used in uncomplicated cystitis in pre-menopausal women is expected to be associated with lower efficacy than the longer treatment duration. This is all the more to be taken into account as regards the increasing resistance level of \*Escherichia coli\* to quinolones.
\*\*Intra-abdominal infections\*\*
There are limited data on the efficacy of ciprofloxacin in the treatment of post-surgical intra-abdominal infections.
\*\*Travellers' diarrhoea\*\*
The choice of ciprofloxacin should take into account information on resistance to ciprofloxacin in relevant pathogens in the countries visited.
\*\*Infections of the bones and joints\*\*
Ciprofloxacin should be used in combination with other antimicrobial agents depending on the results of the microbiological documentation.
\*\*Inhalational anthrax\*\*
Use in humans is based on \*in-vitro\* susceptibility data and on animal experimental data together with limited human data. Treating physicians should refer to national and /or international consensus documents regarding the treatment of anthrax.
\*\*Paediatric population\*\*
The use of ciprofloxacin in children and adolescents should follow available official guidance. Ciprofloxacin treatment should be initiated only by physicians who are experienced in the treatment of cystic fibrosis and/or severe infections in children and adolescents.
Ciprofloxacin has been shown to cause arthropathy in weight-bearing joints of immature animals. Safety data from a randomised double-blind study on ciprofloxacin use in children (ciprofloxacin: n=335, mean age = 6.3 years; comparators: n=349, mean age = 6.2 years; age range = 1 to 17 years) revealed an incidence of suspected drug-related arthropathy (discerned from joint-related clinical signs and symptoms) by Day +42 of 7.2% and 4.6%. Respectively, an incidence of drug-related arthropathy by 1-year follow-up was 9.0% and 5.7%. The increase of suspected drug-related arthropathy cases over time was not statistically significant between groups. Treatment should be initiated only after a careful benefit/risk evaluation, due to possible adverse events related to joints and/or surrounding tissue (see section 4.8).
\*Broncho-pulmonary infections in cystic fibrosis\*
Clinical trials have included children and adolescents aged 5-17 years. More limited experience is available in treating children between 1 and 5 years of age.
\*Complicated urinary tract infections and pyelonephritis\*
Ciprofloxacin treatment of urinary tract infections should be considered when other treatments cannot be used, and should be based on the results of the microbiological documentation.
Clinical trials have included children and adolescents aged 1-17 years.
\*Other specific severe infections\*
Other severe infections in accordance with official guidance, or after careful benefit-risk evaluation when other treatments cannot be used, or after failure to conventional therapy and when the microbiological documentation can justify a ciprofloxacin use.
The use of ciprofloxacin for specific severe infections other than those mentioned above has not been evaluated in clinical trials and the clinical experience is limited. Consequently, caution is advised when treating patients with these infections.
\*\*Hypersensitivity\*\*
Hypersensitivity and allergic reactions, including anaphylaxis and anaphylactoid reactions, may occur following a single dose (see section 4.8) and may be life-threatening. If such reaction occurs, ciprofloxacin should be discontinued and an adequate medical treatment is required.
\*\*Tendinitis and tendon rupture\*\*
Ciprofloxacin should generally not be used in patients with a history of tendon disease/disorder related to quinolone treatment. Nevertheless, in very rare instances, after microbiological documentation of the causative organism and evaluation of the risk/benefit balance, ciprofloxacin may be prescribed to these patients for the treatment of certain severe infections, particularly in the event of failure of the standard therapy or bacterial resistance, where the microbiological data may justify the use of ciprofloxacin.
Tendinitis and tendon rupture (especially but not limited to Achilles tendon), sometimes bilateral, may occur as early as within 48 hours of starting treatment with quinolones and fluoroquinolones and have been reported to occur even up to several months after discontinuation of treatment (see section 4.8). The risk of tendinitis and tendon rupture is increased in older patients, patients with renal impairment, patients with solid organ transplants, and those treated concurrently with corticosteroids. Therefore, concomitant use of corticosteroids should be avoided.
At the first sign of tendinitis (e.g. painful swelling, inflammation) the treatment with Ciprofloxacin should be discontinued and alternative treatment should be considered. The affected limb(s) should be appropriately treated (e.g. immobilisation). Corticosteroids should not be used if signs of tendinopathy occur.
\*\*Patients with myasthenia gravis\*\*
Ciprofloxacin should be used with caution in patients with myasthenia gravis, because symptoms can be exacerbated (see section 4.8).
\*\*Aortic aneurysm and dissection, and heart valve regurgitation/incompetence\*\*
Epidemiologic studies report an increased risk of aortic aneurysm and dissection, particularly in elderly patients, and of aortic and mitral valve regurgitation after intake of fluoroquinolones. Cases of aortic aneurysm and dissection, sometimes complicated by rupture (including fatal ones), and of regurgitation/incompetence of any of the heart valves have been reported in patients receiving fluoroquinolones (see section 4.8).
Therefore, fluoroquinolones should only be used after careful benefit-risk assessment and after consideration of other therapeutic options in patients with positive family history of aneurysm disease or congenital heart valve disease, or in patients diagnosed with pre-existing aortic aneurysm and/or dissection or heart valve disease, or in presence of other risk factors or conditions predisposing:
- for both aortic aneurysm and dissection and heart valve regurgitation/incompetence (e.g. connective tissue disorders such as Marfan syndrome or Ehlers-Danlos syndrome, Turner syndrome, Behcet's disease, hypertension, rheumatoid arthritis) or additionally
- for aortic aneurysm and dissection (e.g. vascular disorders such as Takayasu arteritis or giant cell arteritis, or known atherosclerosis, or Sjögren's syndrome) or additionally
- for heart valve regurgitation/incompetence (e.g. infective endocarditis).
The risk of aortic aneurysm and dissection, and their rupture may also be increased in patients treated concurrently with systemic corticosteroids.
In case of sudden abdominal, chest or back pain, patients should be advised to immediately consult a physician in an emergency department.
Patients should be advised to seek immediate medical attention in case of acute dyspnoea, new onset of heart palpitations, or development of oedema of the abdomen or lower extremities.
\*\*Vision disorders\*\*
If vision becomes impaired or any effects on the eyes are experienced, an eye specialist should be consulted immediately.
\*\*Photosensitivity\*\*
Ciprofloxacin has been shown to cause photosensitivity reactions. Patients taking ciprofloxacin should be advised to avoid direct exposure to either extensive sunlight or UV irradiation during treatment (see section 4.8).
\*\*Seizures\*\*
Ciprofloxacin like other quinolones are known to trigger seizures or lower the seizure threshold. Cases of status epilepticus have been reported. Ciprofloxacin should be used with caution in patients with CNS disorders which may be predisposed to seizure. If seizures occur ciprofloxacin should be discontinued (see section 4.8).
\*\*Peripheral neuropathy\*\*
Cases of sensory or sensorimotor polyneuropathy resulting in paraesthesia, hypaesthesia, dysesthesia, or weakness have been reported in patients receiving quinolones and fluoroquinolones. Patients under treatment with Ciprofloxacin should be advised to inform their doctor prior to continuing treatment if symptoms of neuropathy such as pain, burning, tingling, numbness, or weakness develop in order to prevent the development of potentially irreversible condition (see section 4.8).
\*\*Psychiatric reactions\*\*
Psychiatric reactions may occur even after first administration of ciprofloxacin. In rare cases, depression or psychosis can progress to suicidal ideations/thoughts culminating in attempted suicide or completed suicide. If depression, psychotic reactions, suicide-related thoughts or behavior occur, ciprofloxacin should be discontinued.
\*\*Cardiac disorders\*\*
Caution should be taken when using fluoroquinolones, including ciprofloxacin, in patients with known risk factors for prolongation of the QT interval such as, for example:
• congenital long QT syndrome
• concomitant use of drugs that are known to prolong the QT interval (e.g. Class IA and III anti-arrhythmics, tricyclic antidepressants, macrolides, antipsychotics)
• uncorrected electrolyte imbalance (e.g. hypokalaemia, hypomagnesaemia)
• cardiac disease (e.g. heart failure, myocardial infarction, bradycardia)
Elderly patients and women may be more sensitive to QTc-prolonging medications. Therefore, caution should be taken when using fluoroquinolones, including ciprofloxacin, in these populations.
(See section 4.2 Elderly patients, section 4.5, section 4.8, section 4.9).
\*\*Dysglycaemia\*\*
As with all quinolones, disturbances in blood glucose, including both hypoglycaemia and hyperglycaemia have been reported (see section 4.8), usually in elderly diabetic patients receiving concomitant treatment with an oral hypoglycaemic agent (e.g. glibenclamide) or with insulin. Cases of hypoglycaemic coma have been reported. In diabetic patients, careful monitoring of blood glucose is recommended.
\*\*Gastrointestinal System\*\*
The occurrence of severe and persistent diarrhoea during or after treatment (including several weeks after treatment) may indicate an antibiotic-associated colitis (life-threatening with possible fatal outcome), requiring immediate treatment (see section 4.8). In such cases, ciprofloxacin should immediately be discontinued, and an appropriate therapy initiated. Anti-peristaltic drugs are contraindicated in this situation.
\*\*Renal and urinary system\*\*
Crystalluria related to the use of ciprofloxacin has been reported (see section 4.8). Patients receiving ciprofloxacin should be well hydrated and excessive alkalinity of the urine should be avoided.
\*\*Impaired renal function\*\*
Since ciprofloxacin is largely excreted unchanged via renal pathway dose adjustment is needed in patients with impaired renal function as described in section 4.2 to avoid an increase in adverse drug reactions due to accumulation of ciprofloxacin.
\*\*Hepatobiliary system\*\*
Cases of hepatic necrosis and life-threatening hepatic failure have been reported with ciprofloxacin (see section 4.8). In the event of any signs and symptoms of hepatic disease (such as anorexia, jaundice, dark urine, pruritus, or tender abdomen), treatment should be discontinued.
\*\*Glucose-6-phosphate dehydrogenase deficiency\*\*
Haemolytic reactions have been reported with ciprofloxacin in patients with glucose-6-phosphate dehydrogenase deficiency. Ciprofloxacin should be avoided in these patients unless the potential benefit is considered to outweigh the possible risk. In this case, potential occurrence of haemolysis should be monitored.
\*\*Resistance\*\*
During or following a course of treatment with ciprofloxacin bacteria that demonstrate resistance to ciprofloxacin may be isolated, with or without a clinically apparent superinfection. There may be a particular risk of selecting for ciprofloxacin-resistant bacteria during extended durations of treatment and when treating nosocomial infections and/or infections caused by \*Staphylococcus\* and \*Pseudomonas\* species.
\*\*Cytochrome P450\*\*
Ciprofloxacin inhibits CYP1A2 and thus may cause increased serum concentration of concomitantly administered substances metabolised by this enzyme (e.g. theophylline, clozapine, olanzapine, ropinirole, tizanidine, duloxetine, agomelatine). Therefore, patients taking these substances concomitantly with ciprofloxacin should be monitored closely for clinical signs of overdose, and determination of serum concentrations (e.g. of theophylline) may be necessary (see section 4.5). Co-administration of ciprofloxacin and tizanidine is contra-indicated.
\*\*Methotrexate\*\*
The concomitant use of ciprofloxacin with methotrexate is not recommended (see section 4.5).
\*\*Interaction with tests\*\*
The \*in-vitro\* activity of ciprofloxacin against \*Mycobacterium tuberculosis\* might give false negative bacteriological test results in specimens from patients currently taking ciprofloxacin.
\*\*Information about excipients\*\*
\*\*Benzyl alcohol\*\*
This medicine contains 19.6 mg benzyl alcohol in each bottle, which is equivalent to 19.6 mg/100 ml. Benzyl alcohol may cause allergic reactions.
Benzyl alcohol has been linked with the risk of severe side effects including breathing problems (called "gasping syndrome") in young children and neonates. In young children (less than 3 years old), Ciproxin oral suspension should therefore not be used for longer than one week. In addition, due to the risk of accumulation and toxicity (metabolic acidosis), large amounts of benzyl alcohol should only be administered with caution and if absolutely necessary, especially in subjects with liver or kidney impairment, and is not recommended in pregnant and breast-feeding women (see section 4.6).
\*\*Sucrose Load\*\*
Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or saccharose-isomaltase deficiency, should not take Ciproxin 250 mg/5 mL. As Ciproxin 250 mg/5 mL suspension contains 1.4 g sucrose per 5-mL measuring spoonful, this has to be taken into consideration in terms of daily intake. This is to be considered in patients with diabetes mellitus. Ciproxin 250 mg/5 mL can be harmful to teeth.4.5 Interaction with other medicinal products and other forms of interaction
\*\*Effects of other products on ciprofloxacin:\*\*
\*\*\*Drugs known to prolong QT interval\*\*\*
Ciprofloxacin, like other fluoroquinolones, should be used with caution in patients receiving drugs known to prolong QT interval (e.g. Class IA and III anti-arrhythmics, tricyclic antidepressants, macrolides, antipsychotics) (see section 4.4).
\*\*\*Chelation Complex Formation\*\*\*
The simultaneous administration of ciprofloxacin (oral) and multivalent cation-containing drugs and mineral supplements (e.g. calcium, magnesium, aluminium, iron), polymeric phosphate binders (e.g. sevelamer or lanthanum carbonate), sucralfate or antacids, and highly buffered drugs (e.g. didanosine tablets) containing magnesium, aluminium, or calcium reduces the absorption of ciprofloxacin. Consequently, ciprofloxacin should be administered either 1-2 hours before or at least 4 hours after these preparations. The restriction does not apply to antacids belonging to the class of H2 receptor blockers.
\*\*\*Food and Dairy Products\*\*\*
Dietary calcium as part of a meal does not significantly affect absorption of ciprofloxacin (oral). However, ciprofloxacin oral suspension administered concurrently with dairy products or mineral-fortified drinks (e.g. milk, yoghurt, calcium-fortified orange juice) when these products or drinks are taken alone outside meals, may reduce the absorption of ciprofloxacin.
Consequently, ciprofloxacin oral suspension can be taken during meals containing dairy products or mineral-fortified drinks.
The concurrent administration of dairy products or mineral-fortified drinks taken alone outside meals, with ciprofloxacin oral suspension should be avoided.
However, ciprofloxacin oral suspension could be administered either 1-2 hours before or at least 4 hours after dairy products or mineral-fortified drinks when these products and drinks are taken alone outside meals, such as recommended for drugs containing calcium (see section 4.2).
See also above paragraph Chelation Complex Formation.
\*\*\*Probenecid\*\*\*
Probenecid interferes with renal secretion of ciprofloxacin. Co-administration of probenecid and ciprofloxacin increases ciprofloxacin serum concentrations.
\*\*\*Metoclopramide\*\*\*
Metoclopramide accelerates the absorption of ciprofloxacin (oral) resulting in a shorter time to reach maximum plasma concentrations. No effect was seen on the bioavailability of ciprofloxacin.
\*\*\*Omeprazole\*\*\*
Concomitant administration of ciprofloxacin and omeprazole containing medicinal products results in a slight reduction of Cmax and AUC of ciprofloxacin.
\*\*Effects of ciprofloxacin on other medicinal products:\*\*
\*\*\*Tizanidine\*\*\*
Tizanidine must not be administered together with ciprofloxacin (see section 4.3). In a clinical study with healthy subjects, there was an increase in serum tizanidine concentration (Cmax increase: 7-fold, range: 4 to 21-fold; AUC increase: 10-fold, range: 6 to 24-fold) when given concomitantly with ciprofloxacin. Increased serum tizanidine concentration is associated with a potentiated hypotensive and sedative effect.
\*\*\*Methotrexate\*\*\*
Renal tubular transport of methotrexate may be inhibited by concomitant administration of ciprofloxacin, potentially leading to increased plasma levels of methotrexate and increased risk of methotrexate-associated toxic reactions. The concomitant use is not recommended (see section 4.4).
\*\*\*Theophylline\*\*\*
Concurrent administration of ciprofloxacin and theophylline can cause an undesirable increase in serum theophylline concentration. This can lead to theophylline-induced side effects that may rarely be life threatening or fatal. During the combination, serum theophylline concentrations should be checked and the theophylline dose reduced as necessary (see section 4.4).
\*\*\*Other xanthine derivatives\*\*\*
On concurrent administration of ciprofloxacin and caffeine or pentoxifylline (oxpentifylline), raised serum concentrations of these xanthine derivatives were reported.
\*\*\*Phenytoin\*\*\*
Simultaneous administration of ciprofloxacin and phenytoin may result in increased or reduced serum levels of phenytoin such that monitoring of drug levels is recommended.
\*\*\*Cyclosporin\*\*\*
A transient rise in the concentration of serum creatinine was observed when ciprofloxacin and cyclosporin containing medicinal products were administered simultaneously. Therefore, it is frequently (twice a week) necessary to control the serum creatinine concentrations in these patients.
\*\*\*Vitamin K antagonists\*\*\*
Simultaneous administration of ciprofloxacin with a vitamin K antagonist may augment its anti-coagulant effects. The risk may vary with the underlying infection, age and general status of the patient so that the contribution of ciprofloxacin to the increase in INR (international normalised ratio) is difficult to assess. The INR should be monitored frequently during and shortly after co-administration of ciprofloxacin with a vitamin K antagonist (e.g., warfarin, acenocoumarol, phenprocoumon, or fluindione).
\*\*\*Duloxetine\*\*\*
In clinical studies, it was demonstrated that concomitant use of duloxetine with strong inhibitors of the CYP450 1A2 isozyme such as fluvoxamine, may result in an increase of AUC and Cmax of duloxetine. Although no clinical data are available on a possible interaction with ciprofloxacin, similar effects can be expected upon concomitant administration (see section 4.4).
\*\*\*Ropinirole\*\*\*
It was shown in a clinical study that concomitant use of ropinirole with ciprofloxacin, a moderate inhibitor of the CYP450 1A2 isozyme, results in an increase of Cmax and AUC of ropinirole by 60% and 84%, respectively. Monitoring of ropinirole-related side effects and dose adjustment as appropriate is recommended during and shortly after co-administration with ciprofloxacin (see section 4.4).
\*\*\*Lidocaine\*\*\*
It was demonstrated in healthy subjects that concomitant use of lidocaine containing medicinal products with ciprofloxacin, a moderate inhibitor of CYP450 1A2 isozyme, reduces clearance of intravenous lidocaine by 22%. Although lidocaine treatment was well tolerated, a possible interaction with ciprofloxacin associated with side effects may occur upon concomitant administration.
\*\*\*Clozapine\*\*\*
Following concomitant administration of 250 mg ciprofloxacin with clozapine for 7 days, serum concentrations of clozapine and N-desmethylclozapine were increased by 29% and 31%, respectively. Clinical surveillance and appropriate adjustment of clozapine dosage during and shortly after co-administration with ciprofloxacin are advised (see section 4.4).
\*\*\*Sildenafil\*\*\*
Cmax and AUC of sildenafil were increased approximately twofold in healthy subjects after an oral dose of 50 mg given concomitantly with 500 mg ciprofloxacin. Therefore, caution should be used prescribing ciprofloxacin concomitantly with sildenafil taking into consideration the risks and the benefits.
\*\*Agomelatine\*\*
In clinical studies, it was demonstrated that fluvoxamine, as a strong inhibitor of the CYP450 1A2 isoenzyme, markedly inhibits the metabolism of agomelatine resulting in a 60-fold increase of agomelatine exposure. Although no clinical data are available for a possible interaction with ciprofloxacin, a moderate inhibitor of CYP450 1A2, similar effects can be expected upon concomitant administration (see 'Cytochrome P450' in section 4.4).
\*\*Zolpidem\*\*
Co-administration of ciprofloxacin may increase blood levels of zolpidem, concurrent use is not recommended.4.6 Pregnancy and lactation
\*\*Pregnancy\*\*
The data that are available on administration of ciprofloxacin to pregnant women indicates no malformative or feto/neonatal toxicity of ciprofloxacin. Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity. In juvenile and prenatal animals exposed to quinolones, effects on immature cartilage have been observed, thus, it cannot be excluded that the drug could cause damage to articular cartilage in the human immature organism / foetus (see section 5.3). Additionally, this medicine contains benzyl alcohol, which may accumulate in the organism and cause toxicity in the foetus (see section 4.4).
Therefore, it is not recommended to use Ciproxin oral suspension during pregnancy.
\*\*Breast-feeding\*\*
Ciprofloxacin is excreted in breast milk. Due to the potential risk of articular damage, based on animal data, and because this medicine also contains benzyl alcohol, which may accumulate and a risk in the breastfed child cannot be excluded, Ciproxin oral suspension is not recommended for use during breast-feeding.4.7 Effects on ability to drive and use machines
Due to its neurological effects, ciprofloxacin may affect reaction time. Thus, the ability to drive or to operate machinery may be impaired.4.8 Undesirable effects
The most commonly reported adverse drug reactions (ADRs) are nausea and diarrhoea.
ADRs derived from clinical studies and post-marketing surveillance with Ciprofloxacin (oral, intravenous, and sequential therapy) sorted by categories of frequency are listed below. The frequency analysis takes into account data from both oral and intravenous administration of ciprofloxacin.
| | | | | | |
| --- | --- | --- | --- | --- | --- |
| \*\*System Organ Class\*\* | \*\*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 | \*\*Frequency not known\*\* (cannot be estimated from the available data) |
| \*\*Infections and Infestations\*\* | | Mycotic superinfections | | | |
| \*\*Blood and Lymphatic System Disorders\*\* | | Eosinophilia | Leukopenia Anaemia Neutropenia Leukocytosis Thrombocytopenia Thrombocytaemia | Haemolytic anaemia Agranulocytosis Pancytopenia (life-threatening) Bone marrow depression (life-threatening) | |
| \*\*Immune System Disorders\*\* | | | Allergic reaction Allergic oedema / angiooedema | Anaphylactic reaction Anaphylactic shock (life-threatening) (see section 4.4) Serum sickness-like reaction | |
| \*\*Endocrine disorders\*\* | | | | | Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) |
| \*\*Metabolism and Nutrition Disorders\*\* | | Decreased appetite | Hyperglycaemia Hypoglycaemia (see section 4.4) | | Hypoglycaemic coma (see section 4.4) |
| \*\*Psychiatric Disorders\\*\*\* | | Psychomotor hyperactivity / agitation | Confusion and disorientation Anxiety reaction Abnormal dreams Depression (potentially culminating in suicidal ideations/thoughts or suicide attempts and completed suicide) (see section 4.4) Hallucinations | Psychotic reactions (potentially culminating in suicidal ideations/thoughts or suicide attempts and completed suicide) (see section 4.4) | Mania, incl. hypomania |
| \*\*Nervous System Disorders\\*\*\* | | Headache Dizziness Sleep disorders Taste disorders | Par- and Dysaesthesia Hypoaesthesia Tremor Seizures (including status epilepticus see section 4.4) Vertigo | Migraine Disturbed coordination Gait disturbance Olfactory nerve disorders Intracranial hypertension and pseudotumor cerebri | Peripheral neuropathy and polyneuropathy (see section 4.4) |
| \*\*Eye Disorders\\*\*\* | | | Visual disturbances (e.g. diplopia) | Visual colour distortions | |
| \*\*Ear and Labyrinth Disorders\\*\*\* | | | Tinnitus Hearing loss / Hearing impaired | | |
| \*\*Cardiac Disorders\\*\\*\*\* | | | Tachycardia | | Ventricular arrhythmia, and torsades de pointes (reported predominantly in patients with risk factors for QT prolongation), ECG QT prolonged (see sections 4.4 and 4.9) |
| \*\*Vascular Disorders\\*\\*\*\* | | | Vasodilatation Hypotension Syncope | Vasculitis | |
| \*\*Respiratory, Thoracic and Mediastinal Disorders\*\* | | | Dyspnoea (including asthmatic condition) | | |
| \*\*Gastrointestinal Disorders\*\* | Nausea Diarrhoea | Vomiting Gastrointestinal and abdominal pains Dyspepsia Flatulence | Antibiotic associated colitis (very rarely with possible fatal outcome) (see section 4.4) | Pancreatitis | |
| \*\*Hepatobiliary Disorders\*\* | | Increase in transaminases Increased bilirubin | Hepatic impairment Cholestatic icterus Hepatitis | Liver necrosis (very rarely progressing to life-threatening hepatic failure) (see section 4.4) | |
| \*\*Skin and Subcutaneous Tissue Disorders\*\* | | Rash Pruritus Urticaria | Photosensitivity reactions (see section 4.4) | Petechiae Erythema multiforme Erythema nodosum Stevens-Johnson syndrome (potentially life-threatening) Toxic epidermal necrolysis (potentially life-threatening) | Acute Generalised Exanthematous Pustulosis (AGEP) Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) |
| \*\*Musculoskeletal and Connective Tissue Disorders\\*\*\* | | Musculoskeletal pain (e.g. extremity pain, back pain, chest pain) Arthralgia | Myalgia Arthritis Increased muscle tone and cramping Tendinitis Tendon rupture (predominantly Achilles tendon) (see section 4.4) | Muscular weakness Exacerbation of symptoms of myasthenia gravis (see section 4.4) | |
| \*\*Renal and Urinary Disorders\*\* | | Renal impairment | Renal failure Haematuria Crystalluria (see section 4.4) Tubulointerstitial nephritis | | |
| \*\*General Disorders and Administration Site Conditions\\*\*\* | | Asthenia Fever | Oedema Sweating (hyperhidrosis) | | |
| \*\*Investigations\*\* | | Increase in blood alkaline phosphatase | Increased amylase | | International normalised ratio increased (in patients treated with Vitamin K antagonists) |
\\* Cases of prolonged (up to months or years), disabling and potentially irreversible serious drug reactions affecting several, sometimes multiple, system organ classes and senses (including reactions such as tendonitis, tendon rupture, arthralgia, pain in extremities, gait disturbance, neuropathies associated with paraesthesia, fatigue, psychiatric symptoms, memory impairment, and impairment of hearing, vision, taste and smell) have been reported in association with the use of quinolones and fluoroquinolones in some cases irrespective of pre-existing risk factors (see section 4.4). A range of psychiatric symptoms may occur as part of these side effects, which may include, but are not necessarily limited to, sleep disorders, anxiety, panic attacks, confusion, or depression. There are no pharmacological treatments established to be effective treatments of the symptoms of long lasting or disabling side effects associated with fluoroquinolones. The frequency of these prolonged, disabling and potentially irreversible serious drug reactions cannot be estimated with precision using available data, but the reporting incidence from adverse drug reaction reports indicates the frequency is at minimum between 1/1,000 and 1/10,000 (corresponding to the Rare frequency category).
\\*\\* Cases of aortic aneurysm and dissection, sometimes complicated by rupture (including fatal ones), and of regurgitation/incompetence of any of the heart valves have been reported in patients receiving fluoroquinolones (see section 4.4).
\*\*Paediatric population\*\*
The incidence of arthropathy (arthralgia, arthritis), mentioned above, is referring to data collected in studies with adults. In children, arthropathy is reported to occur commonly (see section 4.4).
\*\*\*\*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, Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.4.9 Overdose
An overdose of 12 g has been reported to lead to mild symptoms of toxicity. An acute overdose of 16 g has been reported to cause acute renal failure.
Symptoms in overdose consist of dizziness, tremor, headache, tiredness, seizures, hallucinations, confusion, abdominal discomfort, renal and hepatic impairment as well as crystalluria and haematuria. Reversible renal toxicity has been reported.
Apart from routine emergency measures, , e.g. ventricular emptying followed by medical carbon, it is recommended to monitor renal function, including urinary pH and acidify, if required, to prevent crystalluria. Patients should be kept well hydrated. Calcium or magnesium containing antacids may theoretically reduce the absorption of ciprofloxacin in overdoses.
Only a small quantity of ciprofloxacin (<10%) is eliminated by haemodialysis or peritoneal dialysis.
In the event of overdose, symptomatic treatment should be implemented. ECG monitoring should be undertaken, because of the possibility of QT interval prolongation.
- Instruction Pharmacology
- 5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Fluoroquinolones, ATC code: J01MA02
\*\*Mechanism of action\*\*
As a fluoroquinolone antibacterial agent, the bactericidal action of ciprofloxacin results from the inhibition of both type II topoisomerase (DNA-gyrase) and topoisomerase IV, required for bacterial DNA replication, transcription, repair and recombination.
\*\*Pharmacokinetic/pharmacodynamic relationship\*\*
Efficacy mainly depends on the relation between the maximum concentration in serum (Cmax) and the minimum inhibitory concentration (MIC) of ciprofloxacin for a bacterial pathogen and the relation between the area under the curve (AUC) and the MIC.
\*\*Mechanism of resistance\*\*
\*In-vitro\* resistance to ciprofloxacin can be acquired through a stepwise process by target site mutations in both DNA gyrase and topoisomerase IV. The degree of cross-resistance between ciprofloxacin and other fluoroquinolones that results is variable. Single mutations may not result in clinical resistance, but multiple mutations generally result in clinical resistance to many or all active substances within the class.
Impermeability and/or active substance efflux pump mechanisms of resistance may have a variable effect on susceptibility to fluoroquinolones, which depends on the physiochemical properties of the various active substances within the class and the affinity of transport systems for each active substance. All \*in-vitro\* mechanisms of resistance are commonly observed in clinical isolates. Resistance mechanisms that inactivate other antibiotics such as permeation barriers (common in \*Pseudomonas aeruginosa)\* and efflux mechanisms may affect susceptibility to ciprofloxacin.
Plasmid-mediated resistance encoded by qnr-genes has been reported.
\*\*Spectrum of antibacterial activity\*\*
Breakpoints separate susceptible strains from strains with intermediate susceptibility and the latter from resistant strains:
\*\*\*EUCAST Recommendations\*\*\*
| | | | |
| --- | --- | --- | --- |
| \*\*Microorganisms\*\* | \*\*Susceptible\*\* | \*\*Resistant\*\* | |
| \*Enterobacteriaceae\* | S ≤ 0.25 mg/L | R > 0.5 mg/L | |
| \*Salmonella spp.\* | S ≤ 0.06 mg/L | R > 0.06 mg/L | |
| \*Pseudomonas\* spp. | S ≤ 0.5 mg/L | R > 0.5 mg/L | |
| \*Acinetobacter\* spp. | S ≤ 1 mg/L | R > 1 mg/L | |
| \*Staphylococcus\* spp.1 | S ≤ 1 mg/L | R > 1 mg/L | |
| \*Haemophilus influenzae\* | S ≤ 0.06 mg/L | R > 0.06 mg/L | |
| \*Moraxella catarrhalis\* | S ≤ 0.125 mg/L | R > 0.125 mg/L | |
| \*Neisseria gonorrhoeae\* | S ≤ 0.03 mg/L | R > 0.06 mg/L | |
| \*Neisseria meningitidis\* | S ≤ 0.03 mg/L | R > 0.03 mg/L | |
| Non-species-related breakpoints \*\*\\*\*\* | S ≤ 0.25 mg/L | R > 0.5 mg/L | |
| 1 \*Staphylococcus\* spp. – breakpoints for ciprofloxacin relate to high dose therapy. \*\\*\* Non-species-related breakpoints have been determined mainly on the basis of PK/PD data and are independent of MIC distributions of specific species. They are for use only for species that have not been given a species-specific breakpoint and not for those species where susceptibility testing is not recommended. | | |
The prevalence of acquired resistance may vary geographically and with time for selected species and local information on resistance is desirable, particularly when treating severe infections. As necessary, expert advice should be sought when the local prevalence of resistance is such that the utility of the agent in at least some types of infections is questionable.
Groupings of relevant species according to ciprofloxacin susceptibility (for \*Streptococcus\* species see section 4.4).
| |
| --- |
| \*\*COMMONLY SUSCEPTIBLE SPECIES\*\* |
| \*\*Aerobic Gram-positive micro-organisms\*\* \*Bacillus anthracis\* (1) |
| \*\*Aerobic Gram-negative micro-organisms\*\* \*Aeromonas\* spp. \*Brucella\* spp\*.\* \*Citrobacter koseri\* \*Francisella tularensis\* \*Haemophilus ducreyi\* \*Haemophilus influenzae\* \\* \*Legionella\* spp. \*Moraxella catarrhalis\* \\* \*Neisseria meningitidis\* \*Pasteurella\* spp. \*Salmonella\* spp.\\* \*Shigella\* spp.\\* \*Vibrio\* spp. \*Yersinia pestis\* |
| \*\*Anaerobic micro-organisms\*\* \*Mobiluncus\* |
| \*\*Other micro-organisms\*\* \*Chlamydia trachomatis\* ($) \*Chlamydia pneumoniae\* ($) \*Mycoplasma hominis\* ($) \*Mycoplasma pneumoniae\* ($) |
| \*\*SPECIES FOR WHICH ACQUIRED RESISTANCE MAY BE A PROBLEM\*\* |
| \*\*Aerobic Gram-positive micro-organisms\*\* \*Enterococcus faecalis\* ($) \*Staphylococcus\* spp.\\*(2) |
| \*\*Aerobic Gram-negative micro-organisms\*\* \*Acinetobacter baumannii+\* \*Burkholderia cepacia+\\*\* \*Campylobacter\* spp.\*+\\*\* \*Citrobacter freundii\\*\* \*Enterobacter aerogenes\* \*Enterobacter cloacae \\*\* \*Escherichia coli\\*\* \*Klebsiella oxytoca\* \*Klebsiella pneumoniae\\*\* \*Morganella morganii\\*\* \*Neisseria gonorrhoeae\\*\* \*Proteus mirabilis\\*\* \*Proteus vulgaris\\*\* \*Providencia\* spp. \*Pseudomonas aeruginosa\\*\* \*Pseudomonas fluorescens\* \*Serratia marcescens\*\\* |
| \*\*Anaerobic micro-organisms\*\* \*Peptostreptococcus\* spp. \*Propionibacterium acnes\* |
| \*\*INHERENTLY RESISTANT ORGANISMS\*\* |
| \*\*Aerobic Gram-positive micro-organisms\*\* \*Actinomyces\* \*Enteroccus faecium\* \*Listeria monocytogenes\* |
| \*\*Aerobic Gram-negative micro-organisms\*\* \*Stenotrophomonas maltophilia\* |
| \*\*Anaerobic micro-organisms\*\* Excepted as listed above |
| \*\*Other micro-organisms\*\* \*Mycoplasma genitalium\* \*Ureaplasma urealitycum\* |
| \\* Clinical efficacy has been demonstrated for susceptible isolates in approved clinical indications. + Resistance rate ≥ 50% in one or more EU countries. ($): Natural intermediate susceptibility in the absence of acquired mechanism of resistance (1): Studies have been conducted in experimental animal infections due to inhalations of \*Bacillus anthracis\* spores; these studies reveal that antibiotics starting early after exposition avoid the occurrence of the disease if the treatment is made up to the decrease of the number of spores in the organism under the infective dose. The recommended use in human subjects is based primarily on \*in-vitro\* susceptibility and on animal experimental data together with limited human data. Two-month treatment duration in adults with oral ciprofloxacin given at the following dose, 500 mg bid, is considered as effective to prevent anthrax infection in humans. The treating physician should refer to national and /or international consensus documents regarding treatment of anthrax. (2): Methicillin-resistant \*S. aureus\* very commonly express co-resistance to fluoroquinolones. The rate of resistance to methicillin is around 20 to 50% among all staphylococcal species and is usually higher in nosocomial isolates. |5.2 Pharmacokinetic properties
\*\*Absorption\*\*
Following oral administration of single doses of 250 mg, 500 mg, and 750 mg of ciprofloxacin tablets, ciprofloxacin is absorbed rapidly and extensively, mainly from the small intestine, reaching maximum serum concentrations 1-2 hours later.
Single doses of 100-750 mg produced dose-dependent maximum serum concentrations (Cmax) between 0.56 and 3.7 mg/L. Serum concentrations increase proportionately with doses up to 1000 mg.
The absolute bioavailability is approximately 70-80%.
A 500 mg oral dose given every 12 hours has been shown to produce an area under the serum concentration-time curve (AUC) equivalent to that produced by an intravenous infusion of 400 mg ciprofloxacin given over 60 minutes every 12 hours.
The pharmacokinetics of ciprofloxacin oral suspension 250 mg/5 mL and 500 mg/5 mL are similar to those of tablets.
\*\*Distribution\*\*
Protein binding of ciprofloxacin is low (20-30%). Ciprofloxacin is present in plasma largely in a non-ionised form and has a large steady state distribution volume of 2-3 L/kg body weight. Ciprofloxacin reaches high concentrations in a variety of tissues such as lung (epithelial fluid, alveolar macrophages, biopsy tissue), sinuses, inflamed lesions (cantharides blister fluid), and the urogenital tract (urine, prostate, endometrium) where total concentrations exceeding those of plasma concentrations are reached.
\*\*Biotransformation\*\*
Low concentrations of four metabolites have been reported, which were identified as: desethyleneciprofloxacin (M 1), sulphociprofloxacin (M 2), oxociprofloxacin (M 3) and formylciprofloxacin (M 4). The metabolites display \*in-vitro\* antimicrobial activity but to a lower degree than the parent compound.
Ciprofloxacin is known to be a moderate inhibitor of the CYP 450 1A2 iso-enzymes.
\*\*Elimination\*\*
Ciprofloxacin is largely excreted unchanged both renally and, to a smaller extent, faecally. The serum elimination half-life in subjects with normal renal function is approximately 4-7 hours.
| | | |
| --- | --- | --- |
| \*\*Excretion of ciprofloxacin (% of dose)\*\* | | |
| | \*\*Oral Administration\*\* | |
| \*\*Urine\*\* | \*\*Faeces\*\* |
| Ciprofloxacin | 44.7 | 25.0 |
| Metabolites (M1-M4) | 11.3 | 7.5 |
Renal clearance is between 180-300 mL/kg/h and the total body clearance is between 480-600 mL/kg/h. Ciprofloxacin undergoes both glomerular filtration and tubular secretion. Severely impaired renal function leads to increased half lives of ciprofloxacin of up to 12 h.
Non-renal clearance of ciprofloxacin is mainly due to active trans-intestinal secretion and metabolism. 1% of the dose is excreted via the biliary route. Ciprofloxacin is present in the bile in high concentrations.
\*\*Paediatric patients\*\*
The pharmacokinetic data in paediatric patients are limited.
In a study in children Cmax and AUC were not age-dependent (above one year of age). No notable increase in Cmax and AUC upon multiple dosing (10 mg/kg three times daily) was observed.
In 10 children with severe sepsis Cmax was 6.1 mg/L (range 4.6-8.3 mg/L) after a 1-hour intravenous infusion of 10 mg/kg in children aged less than 1 year compared to 7.2 mg/L (range 4.7-11.8 mg/L) for children between 1 and 5 years of age. The AUC values were 17.4 mg\\*h/L (range 11.8-32.0 mg\\*h/L) and 16.5 mg\\*h/L (range 11.0-23.8 mg\\*h/L) in the respective age groups.
These values are within the range reported for adults at therapeutic doses. Based on population pharmacokinetic analysis of paediatric patients with various infections, the predicted mean half-life in children is approx. 4-5 hours and the bioavailability of the oral suspension ranges from 50 to 80%.5.3 Preclinical safety data
Non-clinical data reveal no special hazards for humans based on conventional studies of single dose toxicity, repeated dose toxicity, carcinogenic potential, or toxicity to reproduction.
Like a number of other quinolones, ciprofloxacin is phototoxic in animals at clinically relevant exposure levels. Data on photomutagenicity/ photocarcinogenicity show a weak photomutagenic or phototumorigenic effect of ciprofloxacin \*in-vitro\* and in animal experiments. This effect was comparable to that of other gyrase inhibitors.
\*\*Articular tolerability\*\*
As reported for other gyrase inhibitors, ciprofloxacin causes damage to the large weight-bearing joints in immature animals. The extent of the cartilage damage varies according to age, species and dose; the damage can be reduced by taking the weight off the joints. Studies with mature animals (rat, dog) revealed no evidence of cartilage lesions. In a study in young beagle dogs, ciprofloxacin caused severe articular changes at therapeutic doses after two weeks of treatment, which were still observed after 5 months.
- Instruction Pharmaceutical Particulars
- 6.1 List of excipients
\*\*Granules\*\*
Hypromellose,
Magnesium stearate,
Polyacrylate dispersion 30 %,
Polysorbate 20,
Povidone.
\*\*Solvent\*\*
Soya lecithin,
Medium chain triglycerides,
Strawberry flavour (contains benzyl alcohol),
Sucrose,
Purified water.6.2 Incompatibilities
No additions should be made to the mixed final ciprofloxacin suspension.6.3 Shelf life
\*\*Shelf life as packaged for sale\*\*
2 years
\*\*Shelf life of the reconstituted oral suspension\*\*
14 days6.4 Special precautions for storage
\*\*Granules\*\*
Do not store above 25 °C.
\*\*Solvent\*\*
Do not store above 25 °C. Protect from freezing. Avoid inverted storage.
Occasionally, a slight yellow layer is observed on the surface of the sugar in the suspension. This has no influence on the pharmaceutical quality of the product.
The ready-to-use oral suspension utilizing these individual components is stable only for 14 days when stored either at ambient temperatures up to 30 °C, or in a refrigerator (2 °C-8 °C). After this time, the reconstituted oral suspension should not be taken. Protect the reconstituted oral suspension from freezing.6.5 Nature and contents of container
\*\*For the granules\*\*
30 mL brown type 3 glass bottle with white opaque PP/PE screw cap (child proof)
\*\*For the solvent\*\*
150 mL white HDPE bottle with child proof and tamper proof PP screw cap
\*\*For the measuring spoon\*\*
Blue 5 mL measuring spoon (PE).
\*\*Pack sizes\*\*
Pack with one brown glass bottle containing 7.95 g of granules and one white HDPE bottle containing 93 mL of solvent. The pack size is provided with a blue plastic graduated measuring spoon.
Pack with two brown glass bottles containing 7.95 g of granules and two white HDPE bottles each containing 93 mL of solvent. The pack size is provided with two blue plastic graduated measuring spoons.
Pack with five brown glass bottles each containing 7.95 g of granules and five white HDPE bottles each containing 93 mL of solvent. The pack size is provided with five blue plastic graduated measuring spoons.
Not all pack sizes may be marketed.6.6 Special precautions for disposal and other handling
The small brown bottle contains the active substance as granules and the large white bottle contains the solvent.
\*\*Reconstitution\*\*
1. Open both bottles. Child proof cap: Press down according to instructions on the cap while turning to the left.
2. Pour the content of the brown bottle (granules) completely into the large white bottle with the suspension fluid. Do not pour water into the suspension!
3. Reclose the large white bottle properly according to the instructions on the cap and shake vigorously for about 15 seconds. The correct mixture is now prepared; the suspension is ready-to-use.
\*\*Taking the Ready-to-Use Suspension\*\*
Take the prescribed amount of suspension by using the measuring spoon. Do not chew the granules present in the suspension, simply swallow them. A drink of water may be taken afterwards. Reclose the bottle properly after use according to the instructions on the cap. The ready-to-use suspension is stable for 14 days when stored in a refrigerator (2 °C-8 °C) or at ambient temperatures below 30°C. After treatment has been completed, it should not be reused. \*\*Shake vigorously each time before use for approximately 15 seconds.\*\*
The graduated measuring spoon with the markings 1/2 is equivalent to 2.6 mL containing 2.5 mL of final suspension and 1/1 is equivalent to 5.2 mL containing 5.0 mL of final suspension. The graduated measuring spoon must be used for measuring the required prescribed amount of Ciprofloxacin oral suspension 250 mg/5 mL.
After use the graduated measuring spoon should be cleaned under running water with dishwashing detergent, rinsed with water and dried thoroughly afterwards with a clean paper towel. The spoon should be stored with the Ciprofloxacin 250 mg/5 mL oral suspension bottle in the outer carton.
- Instruction Content
- ## Composition
5 mL suspension after reconstitution (1 measuring spoon) contains 250 mg ciprofloxacin.
2.5 mL suspension after reconstitution (1/2 measuring spoon) contains 125 mg ciprofloxacin.
Excipients with known effect: benzyl alcohol, sucrose.
One measuring spoon (5 mL of suspension) contains approx. 1.4 g of sucrose.
For the full list of excipients, see section 6.1.
## Pharmaceutical Form
Granules and solvent for oral suspension.
Appearance before reconstitution:
Granules: white to slightly yellowish granules
Solvent: white to slightly yellowish suspension
## Clinical Particulars
4.1 Therapeutic indications
Because of the risk of prolonged, disabling and potentially irreversible serious adverse drug reactions (see section 4.4 and section 4.8) this product must only be prescribed when other antibiotics that are commonly recommended for the infection are inappropriate. This applies to all indications listed below. Situations where other antibiotics are considered to be inappropriate are where:
• there is resistance to other first-line antibiotics recommended for the infection;
• other first-line antibiotics are contraindicated in an individual patient;
• other first-line antibiotics have caused side effects requiring treatment to be stopped;
• treatment with other first-line antibiotics has failed.
The Ciproxin 250 mg/5 mL oral suspension is indicated for the treatment of the following infections (see sections 4.4 and 5.1). Special attention should be paid to available information on resistance to ciprofloxacin before commencing therapy.
Consideration should be given to official guidance on the appropriate use of antibacterial agents.
\*\*Adults\*\*
• Lower respiratory tract infections due to Gram-negative bacteria
- exacerbation of chronic obstructive pulmonary disease.
- broncho-pulmonary infections in cystic fibrosis or in bronchiectasis
- pneumonia
• Chronic suppurative otitis media
• Acute exacerbation of chronic sinusitis especially if these are caused by Gram-negative bacteria
• Urinary tract infections
- Uncomplicated acute cystitis.
- Acute pyelonephritis
- Complicated urinary tract infections
- Bacterial prostatitis
• Genital tract infections
- gonococcal uretritis and cervicitis due to susceptible \*Neisseria gonorrhoeae\*
- epididymo-orchitis including cases due to susceptible \*Neisseria gonorrhoeae\*
- pelvic inflammatory disease including cases due to susceptible \*Neisseria gonorrhoeae\*
• Infections of the gastro-intestinal tract (e.g. travellers' diarrhoea)
• Intra-abdominal infections
• Infections of the skin and soft tissue caused by Gram-negative bacteria
• Malignant external otitis
• Infections of the bones and joints
• Prophylaxis of invasive infections due to \*Neisseria meningitidis\*
• Inhalation anthrax (post-exposure prophylaxis and curative treatment)
Ciprofloxacin may be used in the management of neutropenic patients with fever that is suspected to be due to a bacterial infection.
\*\*Children and adolescents\*\*
• Broncho-pulmonary infections due to \*Pseudomonas aeruginosa\* in patients with cystic fibrosis
• Complicated urinary tract infections and acute pyelonephritis
• Inhalation anthrax (post-exposure prophylaxis and curative treatment)
Ciprofloxacin may also be used to treat severe infections in children and adolescents when this is considered to be necessary.
Treatment should be initiated only by physicians who are experienced in the treatment of cystic fibrosis and/or severe infections in children and adolescents (see sections 4.4 and 5.1).4.2 Posology and method of administration
\*\*Posology\*\*
The dosage is determined by the indication, the severity and the site of the infection, the susceptibility to ciprofloxacin of the causative organism(s), the renal function of the patient and, in children and adolescents the body weight.
The duration of treatment depends on the severity of the illness and on the clinical and bacteriological course.
Treatment of infections due to certain bacteria (e.g. \*Pseudomonas aeruginosa\*, \*Acinetobacter\* or \*Staphylococci\*) may require higher ciprofloxacin doses and co-administration with other appropriate antibacterial agents.
Treatment of some infections (e.g. pelvic inflammatory disease, intra-abdominal infections, infections in neutropenic patients and infections of bones and joints) may require co-administration with other appropriate antibacterial agents depending on the pathogens involved.
\*\*\*Adults\*\*\*
| | | | | |
| --- | --- | --- | --- | --- |
| \*\*Indications\*\* | | \*\*Daily dose in mg\*\* | \*\*Daily dose in mL\*\* \*\*(Number of 5-mL measuring spoonfuls)\*\* | \*\*Total duration of treatment (potentially including initial parenteral treatment with ciprofloxacin)\*\* |
| Infections of the lower respiratory tract | | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15 mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | 7 to 14 days |
| Infections of the upper respiratory tract | Acute exacerbation of chronic sinusitis | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15 mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | 7 to 14 days |
| Chronic suppurative otitis media | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15 mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | 7 to 14 days |
| Malignant external otitis | 750 mg twice daily | 15 mL twice daily (three 5-mL measuring spoonfuls twice daily) | 28 days up to 3 months |
| Urinary tract infections (see section 4.4) | Uncomplicated acute cystitis | 250 mg twice daily to 500 mg twice daily | 5-mL twice daily to 10 mL twice daily (one 5-mL measuring spoonful twice daily up to two 5-mL measuring spoonfuls twice daily) | 3 days |
| In pre-menopausal women, 500 mg single dose may be used corresponding to 10 mL single dose = two 5-mL measuring spoonfuls as a single dose | | |
| Complicated cystitis, Acute pyelonephritis | 500 mg twice daily | 10 mL twice daily (two 5-mL measuring spoonfuls twice daily) | 7 days |
| Complicated pyelonephritis | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15-mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | at least 10 days, it can be continued for longer than 21 days in some specific circumstances (such as abscesses) |
| Bacterial prostatitis | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15-mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | 2 to 4 weeks (acute) to 4 to 6 weeks (chronic) |
| Genital tract infections | Gonococcal uretritis and cervicitis due to susceptible \*Neisseria gonorrhoeae\* | 500 mg as a single dose | 10 mL as a single dose corresponding to two 5-mL measuring spoonfuls as a single dose | 1 day (single dose) |
| Epididymo-orchitis and pelvic inflammatory diseases including cases due to susceptible \*Neisseria gonorrhoeae\* | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15-mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | at least 14 days |
| Infections of the gastro-intestinal tract and intra-abdominal infections | Diarrhoea caused by bacterial pathogens including \*Shigella\* spp. other than \*Shigella\* \*dysenteriae\* type 1 and empirical treatment of severe travellers' diarrhoea | 500 mg twice daily | 10 mL twice daily (two 5-mL measuring spoonfuls twice daily) | 1 day |
| Diarrhoea caused by \*Shigella\* \*dysenteriae\* type 1 | 500 mg twice daily | 10 mL twice daily (two 5-mL measuring spoonfuls twice daily) | 5 days |
| Diarrhoea caused by \*Vibrio\* \*cholerae\* | 500 mg twice daily | 10 mL twice daily (two 5-mL measuring spoonfuls twice daily) | 3 days |
| Typhoid fever | 500 mg twice daily | 10 mL twice daily (two 5-mL measuring spoonfuls twice daily) | 7 days |
| Intra-abdominal infections due to Gram-negative bacteria | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15-mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | 5 to 14 days |
| Infections of the skin and soft tissue caused by Gram-negative bacteria | | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15-mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | 7 to 14 days |
| Bone and joint infections | | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15-mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | max. of 3 months |
| Neutropenic patients with fever that is suspected to be due to a bacterial infection. Ciprofloxacin should be co-administered with appropriate antibacterial agent(s) in accordance to official guidance. | | 500 mg twice daily to 750 mg twice daily | 10 mL twice daily to 15-mL twice daily (two 5-mL measuring spoonfuls twice daily up to three 5-mL measuring spoonfuls twice daily) | Therapy should be continued over the entire period of neutropenia |
| Prophylaxis of invasive infections due to \*Neisseria meningitidis\* | | 500 mg as a single dose | 10 mL as a single dose corresponding to two 5-mL measuring spoonfuls as a single dose | 1 day (single dose) |
| Inhalation anthrax post-exposure prophylaxis and curative treatment for persons able to receive treatment by oral route when clinically appropriate. Drug administration should begin as soon as possible after suspected or confirmed exposure. | | 500 mg twice daily | 10 mL twice daily (two 5-mL measuring spoonfuls twice daily) | 60 days from the confirmation of \*Bacillus anthracis\* exposure |
\*\*\*Paediatric population\*\*\*
| | | |
| --- | --- | --- |
| \*\*Indications\*\* | \*\*Daily dose in mg and in mL\*\* For practical guidance on the number of measuring spoonfuls, refer to table A below | \*\*Total duration of treatment (potentially including initial parenteral treatment with ciprofloxacin)\*\* |
| Cystic fibrosis | 20 mg/kg body weight twice daily with a maximum of 750 mg per dose, corresponding to a 0.4 mL/kg body weight twice daily with a maximum of 15-mL per each of the two daily administrations for the 250mg/5mL suspension | 10 to 14 days |
| Complicated urinary tract infections and acute pyelonephritis | 10 mg/kg body weight twice daily to 20 mg/kg body weight twice daily with a maximum of 750 mg per dose, corresponding to a 0.2 mL/kg body weight twice daily to 0.4 mL/kg body weight twice daily with a maximum of 15-mL per each of the two daily administrations for the 250mg/5mL suspension | 10 to 21 days |
| Inhalation anthrax post-exposure prophylaxis and curative treatment for persons able to receive treatment by oral route when clinically appropriate. Drug administration should begin as soon as possible after suspected or confirmed exposure. | 10 mg/kg body weight twice daily to 15 mg/kg body weight twice daily with a maximum of 500 mg per dose, corresponding to a 0.2 mL/kg body weight twice daily to 0.3 mL/kg body weight twice daily with a maximum of 10 mL per each of the two daily administrations for the 250mg/5mL suspension | 60 days from the confirmation of \*Bacillus anthracis\* exposure |
| Other severe infections | 20 mg/kg body weight twice daily with a maximum of 750 mg per dose, corresponding to a 0.4 mL/kg body weight twice daily with a maximum of 15-mL per each of the two daily administrations for the 250mg/5mL suspension | According to the type of infections |
\*\*Table A: 250 mg/5 mL oral suspension – Practical guidance on the number of measuring spoonfuls to be administered twice daily (every 12 hours)\*\*
| | | |
| --- | --- | --- |
| \*\*250 mg/5 mL oral suspension\*\* ½ spoon = 125 mg ; 1 spoon = 250 mg ; 1 spoon + ½ spoon = 375 mg ; 2 spoons = 500 mg ; 2 spoons + ½ spoon = 625 mg ; 3 spoons = 750 mg (max dose) | | |
| \*\*Body weight (kg)\*\* | \*\*Practical guidance for each of the two daily administrations of Ciproxin oral suspension per recommended dose in mg/kg bodyweight and indications as stated above\*\* | |
| | \*\*10 mg/kg\*\* | \*\*20 mg/kg\*\* |
| 9-10 kg | ½ spoon | 1 spoon\\* |
| 11-15 kg | ½ spoon | 1 spoon |
| 16-20 kg | 1 spoon | 1 spoon + ½ spoon |
| 21-25 kg | 1 spoon | 2 spoons |
| 26-28 kg | 1 spoon | 2 spoons + ½ spoon |
| 29-31 kg | 1 spoon + ½ spoon | 2 spoons + ½ spoon |
| 32-40 kg | 1 spoon + ½ spoon | 3 spoons |
| 41-51 kg | 2 spoons | 3 spoons |
| 52-61 kg | 2 spoons + ½ spoon | 3 spoons |
| 62 kg and above | 3 spoons | 3 spoons |
| \\* The administration of number of measuring spoonfuls leads to an actual dose more than 20 % above the recommended maximum dose per bodyweight | | |
\*\*\*Elderly patients\*\*\*
Elderly patients should receive a dose selected according to the severity of the infection and the patient's creatinine clearance.
\*\*\*Patients with renal and hepatic impairment\*\*\*
Recommended starting and maintenance doses for patients with impaired renal function:
| | | |
| --- | --- | --- |
| \*\*Creatinine Clearance [mL/min/ 1.73 m²]\*\* | \*\*Serum Creatinine [µmol/L]\*\* | \*\*Oral Dose [mg]\*\* |
| > 60 | < 124 | See Usual Dosage. |
| 30-60 | 124 to 168 | 250-500 mg every 12 h |
| < 30 | > 169 | 250-500 mg every 24 h |
| Patients on haemodialysis | > 169 | 250-500 mg every 24 h (after dialysis) |
| Patients on peritoneal dialysis | > 169 | 250-500 mg every 24 h |
In patients with impaired liver function no dose adjustment is required.
Dosing in children with impaired renal and/or hepatic function has not been studied.
\*\*Method of administration\*\*
Oral suspension can be taken independent of mealtimes.
If a dose is missed, it should be taken anytime but not later than 6 hours prior to the next scheduled dose. If less than 6 hours remain before the next dose, the missed dose should not be taken and treatment should be continued as prescribed with the next scheduled dose. Double doses should not be taken to compensate for a missed dose.
If taken on an empty stomach, the active substance is absorbed more rapidly.
Ciprofloxacin oral suspension can be taken \*\*during meals\*\* containing dairy products or mineral-fortified drinks. However,ciprofloxacin oral suspension should not be administered concurrently with dairy products (e.g. milk, yoghurt) or mineral-fortified fruit juice (e.g. calcium-fortified orange juice) when these products or drinks are \*\*taken alone\*\* outside meals. Nevertheless ciprofloxacin oral suspension could be administered either 1-2 hours before or at least 4 hours after dairy products or mineral-fortified drinks when these products and drinks are taken alone outside meals, such as recommended for drugs containing calcium (see section 4.5, paragraph Food and Dairy Products).
In severe cases or if the patient is unable to take oral suspension (e.g. patients on enteral nutrition), it is recommended to commence therapy with intravenous ciprofloxacin until a switch to oral administration is possible.
For instructions on reconstitution of the product before administration, see section 6.6.
\*\*Appearance of the reconstituted product:\*\*
The reconstituted product is a white to slightly yellowish suspension with strawberry odour. Occasionally the suspension may contain yellow-orange droplets and globular particles.
½ measuring spoonful (approx 2.5 mL suspension) provides approx. 125 mg ciprofloxacin.
1 measuring spoonful (approx 5.0 mL suspension) provides approx. 250 mg ciprofloxacin.
Always use the graduated measuring spoon to obtain the dose for administering the suspension.
No additions should be made to the mixed final ciprofloxacin suspension.4.3 Contraindications
• Hypersensitivity to the active substance, to other quinolones or to any of the excipients listed in section 6.1.
• Concomitant administration of ciprofloxacin and tizanidine (see section 4.5).4.4 Special warnings and precautions for use
The use of Ciprofloxacin should be avoided in patients who have experienced serious adverse reactions in the past when using quinolone or fluoroquinolone containing products (see section 4.8). Treatment of these patients with Ciprofloxacin should only be initiated in the absence of alternative treatment options and after careful benefit/risk assessment (see also section 4.3).
\*\*Prolonged, disabling and potentially irreversible serious adverse drug reactions\*\*
Cases of prolonged (continuing for months or years), disabling and potentially irreversible serious adverse drug reactions affecting different, sometimes multiple, body systems (including musculoskeletal, nervous, psychiatric and senses) have been reported in patients receiving quinolones and fluoroquinolones irrespective of their age and pre-existing risk factors. There are no pharmacological treatments established to be effective treatments of the symptoms of long lasting or disabling side effects associated with fluoroquinolones. Ciprofloxacin should be discontinued immediately at the first signs or symptoms of any serious adverse reaction and patients should be advised to contact their prescriber for advice, so that symptoms can be appropriately investigated and to avoid further exposure which could potentially worsen adverse reactions.
\*\*Severe infections and mixed infections with Gram-positive and anaerobic pathogens\*\*
Ciprofloxacin monotherapy is not suited for treatment of severe infections and infections that might be due to Gram-positive or anaerobic pathogens. In such infections ciprofloxacin must be co-administered with other appropriate antibacterial agents.
\*\*Streptococcal Infections (including Streptococcus pneumoniae)\*\*
Ciprofloxacin is not recommended for the treatment of streptococcal infections due to inadequate efficacy.
\*\*Genital tract infections\*\*
Gonococcal uretritis, cervicitis, epididymo-orchitis and pelvic inflammatory diseases may be caused by fluoroquinolone-resistant \*Neisseria gonorrhoeae\* isolates.
Therefore, ciprofloxacin should be administered for the treatment of gonococcal uretritis or cervicitis only if ciprofloxacin-resistant \*Neisseria gonorrhoeae\* can be excluded.
For epididymo-orchitis and pelvic inflammatory diseases, empirical ciprofloxacin should only be considered in combination with another appropriate antibacterial agent (e.g. a cephalosporin) unless ciprofloxacin-resistant \*Neisseria gonorrhoeae\* can be excluded. If clinical improvement is not achieved after 3 days of treatment, the therapy should be reconsidered.
\*\*Urinary tract infections\*\*
Resistance to fluoroquinolones of \*Escherichia coli\* – the most common pathogen involved in urinary tract infections – varies across the European Union. Prescribers are advised to take into account the local prevalence of resistance in \*Escherichia coli\* to fluoroquinolones.
The single dose of ciprofloxacin that may be used in uncomplicated cystitis in pre-menopausal women is expected to be associated with lower efficacy than the longer treatment duration. This is all the more to be taken into account as regards the increasing resistance level of \*Escherichia coli\* to quinolones.
\*\*Intra-abdominal infections\*\*
There are limited data on the efficacy of ciprofloxacin in the treatment of post-surgical intra-abdominal infections.
\*\*Travellers' diarrhoea\*\*
The choice of ciprofloxacin should take into account information on resistance to ciprofloxacin in relevant pathogens in the countries visited.
\*\*Infections of the bones and joints\*\*
Ciprofloxacin should be used in combination with other antimicrobial agents depending on the results of the microbiological documentation.
\*\*Inhalational anthrax\*\*
Use in humans is based on \*in-vitro\* susceptibility data and on animal experimental data together with limited human data. Treating physicians should refer to national and /or international consensus documents regarding the treatment of anthrax.
\*\*Paediatric population\*\*
The use of ciprofloxacin in children and adolescents should follow available official guidance. Ciprofloxacin treatment should be initiated only by physicians who are experienced in the treatment of cystic fibrosis and/or severe infections in children and adolescents.
Ciprofloxacin has been shown to cause arthropathy in weight-bearing joints of immature animals. Safety data from a randomised double-blind study on ciprofloxacin use in children (ciprofloxacin: n=335, mean age = 6.3 years; comparators: n=349, mean age = 6.2 years; age range = 1 to 17 years) revealed an incidence of suspected drug-related arthropathy (discerned from joint-related clinical signs and symptoms) by Day +42 of 7.2% and 4.6%. Respectively, an incidence of drug-related arthropathy by 1-year follow-up was 9.0% and 5.7%. The increase of suspected drug-related arthropathy cases over time was not statistically significant between groups. Treatment should be initiated only after a careful benefit/risk evaluation, due to possible adverse events related to joints and/or surrounding tissue (see section 4.8).
\*Broncho-pulmonary infections in cystic fibrosis\*
Clinical trials have included children and adolescents aged 5-17 years. More limited experience is available in treating children between 1 and 5 years of age.
\*Complicated urinary tract infections and pyelonephritis\*
Ciprofloxacin treatment of urinary tract infections should be considered when other treatments cannot be used, and should be based on the results of the microbiological documentation.
Clinical trials have included children and adolescents aged 1-17 years.
\*Other specific severe infections\*
Other severe infections in accordance with official guidance, or after careful benefit-risk evaluation when other treatments cannot be used, or after failure to conventional therapy and when the microbiological documentation can justify a ciprofloxacin use.
The use of ciprofloxacin for specific severe infections other than those mentioned above has not been evaluated in clinical trials and the clinical experience is limited. Consequently, caution is advised when treating patients with these infections.
\*\*Hypersensitivity\*\*
Hypersensitivity and allergic reactions, including anaphylaxis and anaphylactoid reactions, may occur following a single dose (see section 4.8) and may be life-threatening. If such reaction occurs, ciprofloxacin should be discontinued and an adequate medical treatment is required.
\*\*Tendinitis and tendon rupture\*\*
Ciprofloxacin should generally not be used in patients with a history of tendon disease/disorder related to quinolone treatment. Nevertheless, in very rare instances, after microbiological documentation of the causative organism and evaluation of the risk/benefit balance, ciprofloxacin may be prescribed to these patients for the treatment of certain severe infections, particularly in the event of failure of the standard therapy or bacterial resistance, where the microbiological data may justify the use of ciprofloxacin.
Tendinitis and tendon rupture (especially but not limited to Achilles tendon), sometimes bilateral, may occur as early as within 48 hours of starting treatment with quinolones and fluoroquinolones and have been reported to occur even up to several months after discontinuation of treatment (see section 4.8). The risk of tendinitis and tendon rupture is increased in older patients, patients with renal impairment, patients with solid organ transplants, and those treated concurrently with corticosteroids. Therefore, concomitant use of corticosteroids should be avoided.
At the first sign of tendinitis (e.g. painful swelling, inflammation) the treatment with Ciprofloxacin should be discontinued and alternative treatment should be considered. The affected limb(s) should be appropriately treated (e.g. immobilisation). Corticosteroids should not be used if signs of tendinopathy occur.
\*\*Patients with myasthenia gravis\*\*
Ciprofloxacin should be used with caution in patients with myasthenia gravis, because symptoms can be exacerbated (see section 4.8).
\*\*Aortic aneurysm and dissection, and heart valve regurgitation/incompetence\*\*
Epidemiologic studies report an increased risk of aortic aneurysm and dissection, particularly in elderly patients, and of aortic and mitral valve regurgitation after intake of fluoroquinolones. Cases of aortic aneurysm and dissection, sometimes complicated by rupture (including fatal ones), and of regurgitation/incompetence of any of the heart valves have been reported in patients receiving fluoroquinolones (see section 4.8).
Therefore, fluoroquinolones should only be used after careful benefit-risk assessment and after consideration of other therapeutic options in patients with positive family history of aneurysm disease or congenital heart valve disease, or in patients diagnosed with pre-existing aortic aneurysm and/or dissection or heart valve disease, or in presence of other risk factors or conditions predisposing:
- for both aortic aneurysm and dissection and heart valve regurgitation/incompetence (e.g. connective tissue disorders such as Marfan syndrome or Ehlers-Danlos syndrome, Turner syndrome, Behcet's disease, hypertension, rheumatoid arthritis) or additionally
- for aortic aneurysm and dissection (e.g. vascular disorders such as Takayasu arteritis or giant cell arteritis, or known atherosclerosis, or Sjögren's syndrome) or additionally
- for heart valve regurgitation/incompetence (e.g. infective endocarditis).
The risk of aortic aneurysm and dissection, and their rupture may also be increased in patients treated concurrently with systemic corticosteroids.
In case of sudden abdominal, chest or back pain, patients should be advised to immediately consult a physician in an emergency department.
Patients should be advised to seek immediate medical attention in case of acute dyspnoea, new onset of heart palpitations, or development of oedema of the abdomen or lower extremities.
\*\*Vision disorders\*\*
If vision becomes impaired or any effects on the eyes are experienced, an eye specialist should be consulted immediately.
\*\*Photosensitivity\*\*
Ciprofloxacin has been shown to cause photosensitivity reactions. Patients taking ciprofloxacin should be advised to avoid direct exposure to either extensive sunlight or UV irradiation during treatment (see section 4.8).
\*\*Seizures\*\*
Ciprofloxacin like other quinolones are known to trigger seizures or lower the seizure threshold. Cases of status epilepticus have been reported. Ciprofloxacin should be used with caution in patients with CNS disorders which may be predisposed to seizure. If seizures occur ciprofloxacin should be discontinued (see section 4.8).
\*\*Peripheral neuropathy\*\*
Cases of sensory or sensorimotor polyneuropathy resulting in paraesthesia, hypaesthesia, dysesthesia, or weakness have been reported in patients receiving quinolones and fluoroquinolones. Patients under treatment with Ciprofloxacin should be advised to inform their doctor prior to continuing treatment if symptoms of neuropathy such as pain, burning, tingling, numbness, or weakness develop in order to prevent the development of potentially irreversible condition (see section 4.8).
\*\*Psychiatric reactions\*\*
Psychiatric reactions may occur even after first administration of ciprofloxacin. In rare cases, depression or psychosis can progress to suicidal ideations/thoughts culminating in attempted suicide or completed suicide. If depression, psychotic reactions, suicide-related thoughts or behavior occur, ciprofloxacin should be discontinued.
\*\*Cardiac disorders\*\*
Caution should be taken when using fluoroquinolones, including ciprofloxacin, in patients with known risk factors for prolongation of the QT interval such as, for example:
• congenital long QT syndrome
• concomitant use of drugs that are known to prolong the QT interval (e.g. Class IA and III anti-arrhythmics, tricyclic antidepressants, macrolides, antipsychotics)
• uncorrected electrolyte imbalance (e.g. hypokalaemia, hypomagnesaemia)
• cardiac disease (e.g. heart failure, myocardial infarction, bradycardia)
Elderly patients and women may be more sensitive to QTc-prolonging medications. Therefore, caution should be taken when using fluoroquinolones, including ciprofloxacin, in these populations.
(See section 4.2 Elderly patients, section 4.5, section 4.8, section 4.9).
\*\*Dysglycaemia\*\*
As with all quinolones, disturbances in blood glucose, including both hypoglycaemia and hyperglycaemia have been reported (see section 4.8), usually in elderly diabetic patients receiving concomitant treatment with an oral hypoglycaemic agent (e.g. glibenclamide) or with insulin. Cases of hypoglycaemic coma have been reported. In diabetic patients, careful monitoring of blood glucose is recommended.
\*\*Gastrointestinal System\*\*
The occurrence of severe and persistent diarrhoea during or after treatment (including several weeks after treatment) may indicate an antibiotic-associated colitis (life-threatening with possible fatal outcome), requiring immediate treatment (see section 4.8). In such cases, ciprofloxacin should immediately be discontinued, and an appropriate therapy initiated. Anti-peristaltic drugs are contraindicated in this situation.
\*\*Renal and urinary system\*\*
Crystalluria related to the use of ciprofloxacin has been reported (see section 4.8). Patients receiving ciprofloxacin should be well hydrated and excessive alkalinity of the urine should be avoided.
\*\*Impaired renal function\*\*
Since ciprofloxacin is largely excreted unchanged via renal pathway dose adjustment is needed in patients with impaired renal function as described in section 4.2 to avoid an increase in adverse drug reactions due to accumulation of ciprofloxacin.
\*\*Hepatobiliary system\*\*
Cases of hepatic necrosis and life-threatening hepatic failure have been reported with ciprofloxacin (see section 4.8). In the event of any signs and symptoms of hepatic disease (such as anorexia, jaundice, dark urine, pruritus, or tender abdomen), treatment should be discontinued.
\*\*Glucose-6-phosphate dehydrogenase deficiency\*\*
Haemolytic reactions have been reported with ciprofloxacin in patients with glucose-6-phosphate dehydrogenase deficiency. Ciprofloxacin should be avoided in these patients unless the potential benefit is considered to outweigh the possible risk. In this case, potential occurrence of haemolysis should be monitored.
\*\*Resistance\*\*
During or following a course of treatment with ciprofloxacin bacteria that demonstrate resistance to ciprofloxacin may be isolated, with or without a clinically apparent superinfection. There may be a particular risk of selecting for ciprofloxacin-resistant bacteria during extended durations of treatment and when treating nosocomial infections and/or infections caused by \*Staphylococcus\* and \*Pseudomonas\* species.
\*\*Cytochrome P450\*\*
Ciprofloxacin inhibits CYP1A2 and thus may cause increased serum concentration of concomitantly administered substances metabolised by this enzyme (e.g. theophylline, clozapine, olanzapine, ropinirole, tizanidine, duloxetine, agomelatine). Therefore, patients taking these substances concomitantly with ciprofloxacin should be monitored closely for clinical signs of overdose, and determination of serum concentrations (e.g. of theophylline) may be necessary (see section 4.5). Co-administration of ciprofloxacin and tizanidine is contra-indicated.
\*\*Methotrexate\*\*
The concomitant use of ciprofloxacin with methotrexate is not recommended (see section 4.5).
\*\*Interaction with tests\*\*
The \*in-vitro\* activity of ciprofloxacin against \*Mycobacterium tuberculosis\* might give false negative bacteriological test results in specimens from patients currently taking ciprofloxacin.
\*\*Information about excipients\*\*
\*\*Benzyl alcohol\*\*
This medicine contains 19.6 mg benzyl alcohol in each bottle, which is equivalent to 19.6 mg/100 ml. Benzyl alcohol may cause allergic reactions.
Benzyl alcohol has been linked with the risk of severe side effects including breathing problems (called "gasping syndrome") in young children and neonates. In young children (less than 3 years old), Ciproxin oral suspension should therefore not be used for longer than one week. In addition, due to the risk of accumulation and toxicity (metabolic acidosis), large amounts of benzyl alcohol should only be administered with caution and if absolutely necessary, especially in subjects with liver or kidney impairment, and is not recommended in pregnant and breast-feeding women (see section 4.6).
\*\*Sucrose Load\*\*
Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or saccharose-isomaltase deficiency, should not take Ciproxin 250 mg/5 mL. As Ciproxin 250 mg/5 mL suspension contains 1.4 g sucrose per 5-mL measuring spoonful, this has to be taken into consideration in terms of daily intake. This is to be considered in patients with diabetes mellitus. Ciproxin 250 mg/5 mL can be harmful to teeth.4.5 Interaction with other medicinal products and other forms of interaction
\*\*Effects of other products on ciprofloxacin:\*\*
\*\*\*Drugs known to prolong QT interval\*\*\*
Ciprofloxacin, like other fluoroquinolones, should be used with caution in patients receiving drugs known to prolong QT interval (e.g. Class IA and III anti-arrhythmics, tricyclic antidepressants, macrolides, antipsychotics) (see section 4.4).
\*\*\*Chelation Complex Formation\*\*\*
The simultaneous administration of ciprofloxacin (oral) and multivalent cation-containing drugs and mineral supplements (e.g. calcium, magnesium, aluminium, iron), polymeric phosphate binders (e.g. sevelamer or lanthanum carbonate), sucralfate or antacids, and highly buffered drugs (e.g. didanosine tablets) containing magnesium, aluminium, or calcium reduces the absorption of ciprofloxacin. Consequently, ciprofloxacin should be administered either 1-2 hours before or at least 4 hours after these preparations. The restriction does not apply to antacids belonging to the class of H2 receptor blockers.
\*\*\*Food and Dairy Products\*\*\*
Dietary calcium as part of a meal does not significantly affect absorption of ciprofloxacin (oral). However, ciprofloxacin oral suspension administered concurrently with dairy products or mineral-fortified drinks (e.g. milk, yoghurt, calcium-fortified orange juice) when these products or drinks are taken alone outside meals, may reduce the absorption of ciprofloxacin.
Consequently, ciprofloxacin oral suspension can be taken during meals containing dairy products or mineral-fortified drinks.
The concurrent administration of dairy products or mineral-fortified drinks taken alone outside meals, with ciprofloxacin oral suspension should be avoided.
However, ciprofloxacin oral suspension could be administered either 1-2 hours before or at least 4 hours after dairy products or mineral-fortified drinks when these products and drinks are taken alone outside meals, such as recommended for drugs containing calcium (see section 4.2).
See also above paragraph Chelation Complex Formation.
\*\*\*Probenecid\*\*\*
Probenecid interferes with renal secretion of ciprofloxacin. Co-administration of probenecid and ciprofloxacin increases ciprofloxacin serum concentrations.
\*\*\*Metoclopramide\*\*\*
Metoclopramide accelerates the absorption of ciprofloxacin (oral) resulting in a shorter time to reach maximum plasma concentrations. No effect was seen on the bioavailability of ciprofloxacin.
\*\*\*Omeprazole\*\*\*
Concomitant administration of ciprofloxacin and omeprazole containing medicinal products results in a slight reduction of Cmax and AUC of ciprofloxacin.
\*\*Effects of ciprofloxacin on other medicinal products:\*\*
\*\*\*Tizanidine\*\*\*
Tizanidine must not be administered together with ciprofloxacin (see section 4.3). In a clinical study with healthy subjects, there was an increase in serum tizanidine concentration (Cmax increase: 7-fold, range: 4 to 21-fold; AUC increase: 10-fold, range: 6 to 24-fold) when given concomitantly with ciprofloxacin. Increased serum tizanidine concentration is associated with a potentiated hypotensive and sedative effect.
\*\*\*Methotrexate\*\*\*
Renal tubular transport of methotrexate may be inhibited by concomitant administration of ciprofloxacin, potentially leading to increased plasma levels of methotrexate and increased risk of methotrexate-associated toxic reactions. The concomitant use is not recommended (see section 4.4).
\*\*\*Theophylline\*\*\*
Concurrent administration of ciprofloxacin and theophylline can cause an undesirable increase in serum theophylline concentration. This can lead to theophylline-induced side effects that may rarely be life threatening or fatal. During the combination, serum theophylline concentrations should be checked and the theophylline dose reduced as necessary (see section 4.4).
\*\*\*Other xanthine derivatives\*\*\*
On concurrent administration of ciprofloxacin and caffeine or pentoxifylline (oxpentifylline), raised serum concentrations of these xanthine derivatives were reported.
\*\*\*Phenytoin\*\*\*
Simultaneous administration of ciprofloxacin and phenytoin may result in increased or reduced serum levels of phenytoin such that monitoring of drug levels is recommended.
\*\*\*Cyclosporin\*\*\*
A transient rise in the concentration of serum creatinine was observed when ciprofloxacin and cyclosporin containing medicinal products were administered simultaneously. Therefore, it is frequently (twice a week) necessary to control the serum creatinine concentrations in these patients.
\*\*\*Vitamin K antagonists\*\*\*
Simultaneous administration of ciprofloxacin with a vitamin K antagonist may augment its anti-coagulant effects. The risk may vary with the underlying infection, age and general status of the patient so that the contribution of ciprofloxacin to the increase in INR (international normalised ratio) is difficult to assess. The INR should be monitored frequently during and shortly after co-administration of ciprofloxacin with a vitamin K antagonist (e.g., warfarin, acenocoumarol, phenprocoumon, or fluindione).
\*\*\*Duloxetine\*\*\*
In clinical studies, it was demonstrated that concomitant use of duloxetine with strong inhibitors of the CYP450 1A2 isozyme such as fluvoxamine, may result in an increase of AUC and Cmax of duloxetine. Although no clinical data are available on a possible interaction with ciprofloxacin, similar effects can be expected upon concomitant administration (see section 4.4).
\*\*\*Ropinirole\*\*\*
It was shown in a clinical study that concomitant use of ropinirole with ciprofloxacin, a moderate inhibitor of the CYP450 1A2 isozyme, results in an increase of Cmax and AUC of ropinirole by 60% and 84%, respectively. Monitoring of ropinirole-related side effects and dose adjustment as appropriate is recommended during and shortly after co-administration with ciprofloxacin (see section 4.4).
\*\*\*Lidocaine\*\*\*
It was demonstrated in healthy subjects that concomitant use of lidocaine containing medicinal products with ciprofloxacin, a moderate inhibitor of CYP450 1A2 isozyme, reduces clearance of intravenous lidocaine by 22%. Although lidocaine treatment was well tolerated, a possible interaction with ciprofloxacin associated with side effects may occur upon concomitant administration.
\*\*\*Clozapine\*\*\*
Following concomitant administration of 250 mg ciprofloxacin with clozapine for 7 days, serum concentrations of clozapine and N-desmethylclozapine were increased by 29% and 31%, respectively. Clinical surveillance and appropriate adjustment of clozapine dosage during and shortly after co-administration with ciprofloxacin are advised (see section 4.4).
\*\*\*Sildenafil\*\*\*
Cmax and AUC of sildenafil were increased approximately twofold in healthy subjects after an oral dose of 50 mg given concomitantly with 500 mg ciprofloxacin. Therefore, caution should be used prescribing ciprofloxacin concomitantly with sildenafil taking into consideration the risks and the benefits.
\*\*Agomelatine\*\*
In clinical studies, it was demonstrated that fluvoxamine, as a strong inhibitor of the CYP450 1A2 isoenzyme, markedly inhibits the metabolism of agomelatine resulting in a 60-fold increase of agomelatine exposure. Although no clinical data are available for a possible interaction with ciprofloxacin, a moderate inhibitor of CYP450 1A2, similar effects can be expected upon concomitant administration (see 'Cytochrome P450' in section 4.4).
\*\*Zolpidem\*\*
Co-administration of ciprofloxacin may increase blood levels of zolpidem, concurrent use is not recommended.4.6 Pregnancy and lactation
\*\*Pregnancy\*\*
The data that are available on administration of ciprofloxacin to pregnant women indicates no malformative or feto/neonatal toxicity of ciprofloxacin. Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity. In juvenile and prenatal animals exposed to quinolones, effects on immature cartilage have been observed, thus, it cannot be excluded that the drug could cause damage to articular cartilage in the human immature organism / foetus (see section 5.3). Additionally, this medicine contains benzyl alcohol, which may accumulate in the organism and cause toxicity in the foetus (see section 4.4).
Therefore, it is not recommended to use Ciproxin oral suspension during pregnancy.
\*\*Breast-feeding\*\*
Ciprofloxacin is excreted in breast milk. Due to the potential risk of articular damage, based on animal data, and because this medicine also contains benzyl alcohol, which may accumulate and a risk in the breastfed child cannot be excluded, Ciproxin oral suspension is not recommended for use during breast-feeding.4.7 Effects on ability to drive and use machines
Due to its neurological effects, ciprofloxacin may affect reaction time. Thus, the ability to drive or to operate machinery may be impaired.4.8 Undesirable effects
The most commonly reported adverse drug reactions (ADRs) are nausea and diarrhoea.
ADRs derived from clinical studies and post-marketing surveillance with Ciprofloxacin (oral, intravenous, and sequential therapy) sorted by categories of frequency are listed below. The frequency analysis takes into account data from both oral and intravenous administration of ciprofloxacin.
| | | | | | |
| --- | --- | --- | --- | --- | --- |
| \*\*System Organ Class\*\* | \*\*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 | \*\*Frequency not known\*\* (cannot be estimated from the available data) |
| \*\*Infections and Infestations\*\* | | Mycotic superinfections | | | |
| \*\*Blood and Lymphatic System Disorders\*\* | | Eosinophilia | Leukopenia Anaemia Neutropenia Leukocytosis Thrombocytopenia Thrombocytaemia | Haemolytic anaemia Agranulocytosis Pancytopenia (life-threatening) Bone marrow depression (life-threatening) | |
| \*\*Immune System Disorders\*\* | | | Allergic reaction Allergic oedema / angiooedema | Anaphylactic reaction Anaphylactic shock (life-threatening) (see section 4.4) Serum sickness-like reaction | |
| \*\*Endocrine disorders\*\* | | | | | Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) |
| \*\*Metabolism and Nutrition Disorders\*\* | | Decreased appetite | Hyperglycaemia Hypoglycaemia (see section 4.4) | | Hypoglycaemic coma (see section 4.4) |
| \*\*Psychiatric Disorders\\*\*\* | | Psychomotor hyperactivity / agitation | Confusion and disorientation Anxiety reaction Abnormal dreams Depression (potentially culminating in suicidal ideations/thoughts or suicide attempts and completed suicide) (see section 4.4) Hallucinations | Psychotic reactions (potentially culminating in suicidal ideations/thoughts or suicide attempts and completed suicide) (see section 4.4) | Mania, incl. hypomania |
| \*\*Nervous System Disorders\\*\*\* | | Headache Dizziness Sleep disorders Taste disorders | Par- and Dysaesthesia Hypoaesthesia Tremor Seizures (including status epilepticus see section 4.4) Vertigo | Migraine Disturbed coordination Gait disturbance Olfactory nerve disorders Intracranial hypertension and pseudotumor cerebri | Peripheral neuropathy and polyneuropathy (see section 4.4) |
| \*\*Eye Disorders\\*\*\* | | | Visual disturbances (e.g. diplopia) | Visual colour distortions | |
| \*\*Ear and Labyrinth Disorders\\*\*\* | | | Tinnitus Hearing loss / Hearing impaired | | |
| \*\*Cardiac Disorders\\*\\*\*\* | | | Tachycardia | | Ventricular arrhythmia, and torsades de pointes (reported predominantly in patients with risk factors for QT prolongation), ECG QT prolonged (see sections 4.4 and 4.9) |
| \*\*Vascular Disorders\\*\\*\*\* | | | Vasodilatation Hypotension Syncope | Vasculitis | |
| \*\*Respiratory, Thoracic and Mediastinal Disorders\*\* | | | Dyspnoea (including asthmatic condition) | | |
| \*\*Gastrointestinal Disorders\*\* | Nausea Diarrhoea | Vomiting Gastrointestinal and abdominal pains Dyspepsia Flatulence | Antibiotic associated colitis (very rarely with possible fatal outcome) (see section 4.4) | Pancreatitis | |
| \*\*Hepatobiliary Disorders\*\* | | Increase in transaminases Increased bilirubin | Hepatic impairment Cholestatic icterus Hepatitis | Liver necrosis (very rarely progressing to life-threatening hepatic failure) (see section 4.4) | |
| \*\*Skin and Subcutaneous Tissue Disorders\*\* | | Rash Pruritus Urticaria | Photosensitivity reactions (see section 4.4) | Petechiae Erythema multiforme Erythema nodosum Stevens-Johnson syndrome (potentially life-threatening) Toxic epidermal necrolysis (potentially life-threatening) | Acute Generalised Exanthematous Pustulosis (AGEP) Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) |
| \*\*Musculoskeletal and Connective Tissue Disorders\\*\*\* | | Musculoskeletal pain (e.g. extremity pain, back pain, chest pain) Arthralgia | Myalgia Arthritis Increased muscle tone and cramping Tendinitis Tendon rupture (predominantly Achilles tendon) (see section 4.4) | Muscular weakness Exacerbation of symptoms of myasthenia gravis (see section 4.4) | |
| \*\*Renal and Urinary Disorders\*\* | | Renal impairment | Renal failure Haematuria Crystalluria (see section 4.4) Tubulointerstitial nephritis | | |
| \*\*General Disorders and Administration Site Conditions\\*\*\* | | Asthenia Fever | Oedema Sweating (hyperhidrosis) | | |
| \*\*Investigations\*\* | | Increase in blood alkaline phosphatase | Increased amylase | | International normalised ratio increased (in patients treated with Vitamin K antagonists) |
\\* Cases of prolonged (up to months or years), disabling and potentially irreversible serious drug reactions affecting several, sometimes multiple, system organ classes and senses (including reactions such as tendonitis, tendon rupture, arthralgia, pain in extremities, gait disturbance, neuropathies associated with paraesthesia, fatigue, psychiatric symptoms, memory impairment, and impairment of hearing, vision, taste and smell) have been reported in association with the use of quinolones and fluoroquinolones in some cases irrespective of pre-existing risk factors (see section 4.4). A range of psychiatric symptoms may occur as part of these side effects, which may include, but are not necessarily limited to, sleep disorders, anxiety, panic attacks, confusion, or depression. There are no pharmacological treatments established to be effective treatments of the symptoms of long lasting or disabling side effects associated with fluoroquinolones. The frequency of these prolonged, disabling and potentially irreversible serious drug reactions cannot be estimated with precision using available data, but the reporting incidence from adverse drug reaction reports indicates the frequency is at minimum between 1/1,000 and 1/10,000 (corresponding to the Rare frequency category).
\\*\\* Cases of aortic aneurysm and dissection, sometimes complicated by rupture (including fatal ones), and of regurgitation/incompetence of any of the heart valves have been reported in patients receiving fluoroquinolones (see section 4.4).
\*\*Paediatric population\*\*
The incidence of arthropathy (arthralgia, arthritis), mentioned above, is referring to data collected in studies with adults. In children, arthropathy is reported to occur commonly (see section 4.4).
\*\*\*\*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, Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.4.9 Overdose
An overdose of 12 g has been reported to lead to mild symptoms of toxicity. An acute overdose of 16 g has been reported to cause acute renal failure.
Symptoms in overdose consist of dizziness, tremor, headache, tiredness, seizures, hallucinations, confusion, abdominal discomfort, renal and hepatic impairment as well as crystalluria and haematuria. Reversible renal toxicity has been reported.
Apart from routine emergency measures, , e.g. ventricular emptying followed by medical carbon, it is recommended to monitor renal function, including urinary pH and acidify, if required, to prevent crystalluria. Patients should be kept well hydrated. Calcium or magnesium containing antacids may theoretically reduce the absorption of ciprofloxacin in overdoses.
Only a small quantity of ciprofloxacin (<10%) is eliminated by haemodialysis or peritoneal dialysis.
In the event of overdose, symptomatic treatment should be implemented. ECG monitoring should be undertaken, because of the possibility of QT interval prolongation.
## Pharmacological Properties
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Fluoroquinolones, ATC code: J01MA02
\*\*Mechanism of action\*\*
As a fluoroquinolone antibacterial agent, the bactericidal action of ciprofloxacin results from the inhibition of both type II topoisomerase (DNA-gyrase) and topoisomerase IV, required for bacterial DNA replication, transcription, repair and recombination.
\*\*Pharmacokinetic/pharmacodynamic relationship\*\*
Efficacy mainly depends on the relation between the maximum concentration in serum (Cmax) and the minimum inhibitory concentration (MIC) of ciprofloxacin for a bacterial pathogen and the relation between the area under the curve (AUC) and the MIC.
\*\*Mechanism of resistance\*\*
\*In-vitro\* resistance to ciprofloxacin can be acquired through a stepwise process by target site mutations in both DNA gyrase and topoisomerase IV. The degree of cross-resistance between ciprofloxacin and other fluoroquinolones that results is variable. Single mutations may not result in clinical resistance, but multiple mutations generally result in clinical resistance to many or all active substances within the class.
Impermeability and/or active substance efflux pump mechanisms of resistance may have a variable effect on susceptibility to fluoroquinolones, which depends on the physiochemical properties of the various active substances within the class and the affinity of transport systems for each active substance. All \*in-vitro\* mechanisms of resistance are commonly observed in clinical isolates. Resistance mechanisms that inactivate other antibiotics such as permeation barriers (common in \*Pseudomonas aeruginosa)\* and efflux mechanisms may affect susceptibility to ciprofloxacin.
Plasmid-mediated resistance encoded by qnr-genes has been reported.
\*\*Spectrum of antibacterial activity\*\*
Breakpoints separate susceptible strains from strains with intermediate susceptibility and the latter from resistant strains:
\*\*\*EUCAST Recommendations\*\*\*
| | | | |
| --- | --- | --- | --- |
| \*\*Microorganisms\*\* | \*\*Susceptible\*\* | \*\*Resistant\*\* | |
| \*Enterobacteriaceae\* | S ≤ 0.25 mg/L | R > 0.5 mg/L | |
| \*Salmonella spp.\* | S ≤ 0.06 mg/L | R > 0.06 mg/L | |
| \*Pseudomonas\* spp. | S ≤ 0.5 mg/L | R > 0.5 mg/L | |
| \*Acinetobacter\* spp. | S ≤ 1 mg/L | R > 1 mg/L | |
| \*Staphylococcus\* spp.1 | S ≤ 1 mg/L | R > 1 mg/L | |
| \*Haemophilus influenzae\* | S ≤ 0.06 mg/L | R > 0.06 mg/L | |
| \*Moraxella catarrhalis\* | S ≤ 0.125 mg/L | R > 0.125 mg/L | |
| \*Neisseria gonorrhoeae\* | S ≤ 0.03 mg/L | R > 0.06 mg/L | |
| \*Neisseria meningitidis\* | S ≤ 0.03 mg/L | R > 0.03 mg/L | |
| Non-species-related breakpoints \*\*\\*\*\* | S ≤ 0.25 mg/L | R > 0.5 mg/L | |
| 1 \*Staphylococcus\* spp. – breakpoints for ciprofloxacin relate to high dose therapy. \*\\*\* Non-species-related breakpoints have been determined mainly on the basis of PK/PD data and are independent of MIC distributions of specific species. They are for use only for species that have not been given a species-specific breakpoint and not for those species where susceptibility testing is not recommended. | | |
The prevalence of acquired resistance may vary geographically and with time for selected species and local information on resistance is desirable, particularly when treating severe infections. As necessary, expert advice should be sought when the local prevalence of resistance is such that the utility of the agent in at least some types of infections is questionable.
Groupings of relevant species according to ciprofloxacin susceptibility (for \*Streptococcus\* species see section 4.4).
| |
| --- |
| \*\*COMMONLY SUSCEPTIBLE SPECIES\*\* |
| \*\*Aerobic Gram-positive micro-organisms\*\* \*Bacillus anthracis\* (1) |
| \*\*Aerobic Gram-negative micro-organisms\*\* \*Aeromonas\* spp. \*Brucella\* spp\*.\* \*Citrobacter koseri\* \*Francisella tularensis\* \*Haemophilus ducreyi\* \*Haemophilus influenzae\* \\* \*Legionella\* spp. \*Moraxella catarrhalis\* \\* \*Neisseria meningitidis\* \*Pasteurella\* spp. \*Salmonella\* spp.\\* \*Shigella\* spp.\\* \*Vibrio\* spp. \*Yersinia pestis\* |
| \*\*Anaerobic micro-organisms\*\* \*Mobiluncus\* |
| \*\*Other micro-organisms\*\* \*Chlamydia trachomatis\* ($) \*Chlamydia pneumoniae\* ($) \*Mycoplasma hominis\* ($) \*Mycoplasma pneumoniae\* ($) |
| \*\*SPECIES FOR WHICH ACQUIRED RESISTANCE MAY BE A PROBLEM\*\* |
| \*\*Aerobic Gram-positive micro-organisms\*\* \*Enterococcus faecalis\* ($) \*Staphylococcus\* spp.\\*(2) |
| \*\*Aerobic Gram-negative micro-organisms\*\* \*Acinetobacter baumannii+\* \*Burkholderia cepacia+\\*\* \*Campylobacter\* spp.\*+\\*\* \*Citrobacter freundii\\*\* \*Enterobacter aerogenes\* \*Enterobacter cloacae \\*\* \*Escherichia coli\\*\* \*Klebsiella oxytoca\* \*Klebsiella pneumoniae\\*\* \*Morganella morganii\\*\* \*Neisseria gonorrhoeae\\*\* \*Proteus mirabilis\\*\* \*Proteus vulgaris\\*\* \*Providencia\* spp. \*Pseudomonas aeruginosa\\*\* \*Pseudomonas fluorescens\* \*Serratia marcescens\*\\* |
| \*\*Anaerobic micro-organisms\*\* \*Peptostreptococcus\* spp. \*Propionibacterium acnes\* |
| \*\*INHERENTLY RESISTANT ORGANISMS\*\* |
| \*\*Aerobic Gram-positive micro-organisms\*\* \*Actinomyces\* \*Enteroccus faecium\* \*Listeria monocytogenes\* |
| \*\*Aerobic Gram-negative micro-organisms\*\* \*Stenotrophomonas maltophilia\* |
| \*\*Anaerobic micro-organisms\*\* Excepted as listed above |
| \*\*Other micro-organisms\*\* \*Mycoplasma genitalium\* \*Ureaplasma urealitycum\* |
| \\* Clinical efficacy has been demonstrated for susceptible isolates in approved clinical indications. + Resistance rate ≥ 50% in one or more EU countries. ($): Natural intermediate susceptibility in the absence of acquired mechanism of resistance (1): Studies have been conducted in experimental animal infections due to inhalations of \*Bacillus anthracis\* spores; these studies reveal that antibiotics starting early after exposition avoid the occurrence of the disease if the treatment is made up to the decrease of the number of spores in the organism under the infective dose. The recommended use in human subjects is based primarily on \*in-vitro\* susceptibility and on animal experimental data together with limited human data. Two-month treatment duration in adults with oral ciprofloxacin given at the following dose, 500 mg bid, is considered as effective to prevent anthrax infection in humans. The treating physician should refer to national and /or international consensus documents regarding treatment of anthrax. (2): Methicillin-resistant \*S. aureus\* very commonly express co-resistance to fluoroquinolones. The rate of resistance to methicillin is around 20 to 50% among all staphylococcal species and is usually higher in nosocomial isolates. |5.2 Pharmacokinetic properties
\*\*Absorption\*\*
Following oral administration of single doses of 250 mg, 500 mg, and 750 mg of ciprofloxacin tablets, ciprofloxacin is absorbed rapidly and extensively, mainly from the small intestine, reaching maximum serum concentrations 1-2 hours later.
Single doses of 100-750 mg produced dose-dependent maximum serum concentrations (Cmax) between 0.56 and 3.7 mg/L. Serum concentrations increase proportionately with doses up to 1000 mg.
The absolute bioavailability is approximately 70-80%.
A 500 mg oral dose given every 12 hours has been shown to produce an area under the serum concentration-time curve (AUC) equivalent to that produced by an intravenous infusion of 400 mg ciprofloxacin given over 60 minutes every 12 hours.
The pharmacokinetics of ciprofloxacin oral suspension 250 mg/5 mL and 500 mg/5 mL are similar to those of tablets.
\*\*Distribution\*\*
Protein binding of ciprofloxacin is low (20-30%). Ciprofloxacin is present in plasma largely in a non-ionised form and has a large steady state distribution volume of 2-3 L/kg body weight. Ciprofloxacin reaches high concentrations in a variety of tissues such as lung (epithelial fluid, alveolar macrophages, biopsy tissue), sinuses, inflamed lesions (cantharides blister fluid), and the urogenital tract (urine, prostate, endometrium) where total concentrations exceeding those of plasma concentrations are reached.
\*\*Biotransformation\*\*
Low concentrations of four metabolites have been reported, which were identified as: desethyleneciprofloxacin (M 1), sulphociprofloxacin (M 2), oxociprofloxacin (M 3) and formylciprofloxacin (M 4). The metabolites display \*in-vitro\* antimicrobial activity but to a lower degree than the parent compound.
Ciprofloxacin is known to be a moderate inhibitor of the CYP 450 1A2 iso-enzymes.
\*\*Elimination\*\*
Ciprofloxacin is largely excreted unchanged both renally and, to a smaller extent, faecally. The serum elimination half-life in subjects with normal renal function is approximately 4-7 hours.
| | | |
| --- | --- | --- |
| \*\*Excretion of ciprofloxacin (% of dose)\*\* | | |
| | \*\*Oral Administration\*\* | |
| \*\*Urine\*\* | \*\*Faeces\*\* |
| Ciprofloxacin | 44.7 | 25.0 |
| Metabolites (M1-M4) | 11.3 | 7.5 |
Renal clearance is between 180-300 mL/kg/h and the total body clearance is between 480-600 mL/kg/h. Ciprofloxacin undergoes both glomerular filtration and tubular secretion. Severely impaired renal function leads to increased half lives of ciprofloxacin of up to 12 h.
Non-renal clearance of ciprofloxacin is mainly due to active trans-intestinal secretion and metabolism. 1% of the dose is excreted via the biliary route. Ciprofloxacin is present in the bile in high concentrations.
\*\*Paediatric patients\*\*
The pharmacokinetic data in paediatric patients are limited.
In a study in children Cmax and AUC were not age-dependent (above one year of age). No notable increase in Cmax and AUC upon multiple dosing (10 mg/kg three times daily) was observed.
In 10 children with severe sepsis Cmax was 6.1 mg/L (range 4.6-8.3 mg/L) after a 1-hour intravenous infusion of 10 mg/kg in children aged less than 1 year compared to 7.2 mg/L (range 4.7-11.8 mg/L) for children between 1 and 5 years of age. The AUC values were 17.4 mg\\*h/L (range 11.8-32.0 mg\\*h/L) and 16.5 mg\\*h/L (range 11.0-23.8 mg\\*h/L) in the respective age groups.
These values are within the range reported for adults at therapeutic doses. Based on population pharmacokinetic analysis of paediatric patients with various infections, the predicted mean half-life in children is approx. 4-5 hours and the bioavailability of the oral suspension ranges from 50 to 80%.5.3 Preclinical safety data
Non-clinical data reveal no special hazards for humans based on conventional studies of single dose toxicity, repeated dose toxicity, carcinogenic potential, or toxicity to reproduction.
Like a number of other quinolones, ciprofloxacin is phototoxic in animals at clinically relevant exposure levels. Data on photomutagenicity/ photocarcinogenicity show a weak photomutagenic or phototumorigenic effect of ciprofloxacin \*in-vitro\* and in animal experiments. This effect was comparable to that of other gyrase inhibitors.
\*\*Articular tolerability\*\*
As reported for other gyrase inhibitors, ciprofloxacin causes damage to the large weight-bearing joints in immature animals. The extent of the cartilage damage varies according to age, species and dose; the damage can be reduced by taking the weight off the joints. Studies with mature animals (rat, dog) revealed no evidence of cartilage lesions. In a study in young beagle dogs, ciprofloxacin caused severe articular changes at therapeutic doses after two weeks of treatment, which were still observed after 5 months.
## Pharmaceutical Particulars
6.1 List of excipients
\*\*Granules\*\*
Hypromellose,
Magnesium stearate,
Polyacrylate dispersion 30 %,
Polysorbate 20,
Povidone.
\*\*Solvent\*\*
Soya lecithin,
Medium chain triglycerides,
Strawberry flavour (contains benzyl alcohol),
Sucrose,
Purified water.6.2 Incompatibilities
No additions should be made to the mixed final ciprofloxacin suspension.6.3 Shelf life
\*\*Shelf life as packaged for sale\*\*
2 years
\*\*Shelf life of the reconstituted oral suspension\*\*
14 days6.4 Special precautions for storage
\*\*Granules\*\*
Do not store above 25 °C.
\*\*Solvent\*\*
Do not store above 25 °C. Protect from freezing. Avoid inverted storage.
Occasionally, a slight yellow layer is observed on the surface of the sugar in the suspension. This has no influence on the pharmaceutical quality of the product.
The ready-to-use oral suspension utilizing these individual components is stable only for 14 days when stored either at ambient temperatures up to 30 °C, or in a refrigerator (2 °C-8 °C). After this time, the reconstituted oral suspension should not be taken. Protect the reconstituted oral suspension from freezing.6.5 Nature and contents of container
\*\*For the granules\*\*
30 mL brown type 3 glass bottle with white opaque PP/PE screw cap (child proof)
\*\*For the solvent\*\*
150 mL white HDPE bottle with child proof and tamper proof PP screw cap
\*\*For the measuring spoon\*\*
Blue 5 mL measuring spoon (PE).
\*\*Pack sizes\*\*
Pack with one brown glass bottle containing 7.95 g of granules and one white HDPE bottle containing 93 mL of solvent. The pack size is provided with a blue plastic graduated measuring spoon.
Pack with two brown glass bottles containing 7.95 g of granules and two white HDPE bottles each containing 93 mL of solvent. The pack size is provided with two blue plastic graduated measuring spoons.
Pack with five brown glass bottles each containing 7.95 g of granules and five white HDPE bottles each containing 93 mL of solvent. The pack size is provided with five blue plastic graduated measuring spoons.
Not all pack sizes may be marketed.6.6 Special precautions for disposal and other handling
The small brown bottle contains the active substance as granules and the large white bottle contains the solvent.
\*\*Reconstitution\*\*
1. Open both bottles. Child proof cap: Press down according to instructions on the cap while turning to the left.
2. Pour the content of the brown bottle (granules) completely into the large white bottle with the suspension fluid. Do not pour water into the suspension!
3. Reclose the large white bottle properly according to the instructions on the cap and shake vigorously for about 15 seconds. The correct mixture is now prepared; the suspension is ready-to-use.
\*\*Taking the Ready-to-Use Suspension\*\*
Take the prescribed amount of suspension by using the measuring spoon. Do not chew the granules present in the suspension, simply swallow them. A drink of water may be taken afterwards. Reclose the bottle properly after use according to the instructions on the cap. The ready-to-use suspension is stable for 14 days when stored in a refrigerator (2 °C-8 °C) or at ambient temperatures below 30°C. After treatment has been completed, it should not be reused. \*\*Shake vigorously each time before use for approximately 15 seconds.\*\*
The graduated measuring spoon with the markings 1/2 is equivalent to 2.6 mL containing 2.5 mL of final suspension and 1/1 is equivalent to 5.2 mL containing 5.0 mL of final suspension. The graduated measuring spoon must be used for measuring the required prescribed amount of Ciprofloxacin oral suspension 250 mg/5 mL.
After use the graduated measuring spoon should be cleaned under running water with dishwashing detergent, rinsed with water and dried thoroughly afterwards with a clean paper towel. The spoon should be stored with the Ciprofloxacin 250 mg/5 mL oral suspension bottle in the outer carton.
