GABAPENTIN MORNINGSIDE

4). Treatment should be given for the shortest possible duration. If this medicine is being used for the treatment of epilepsy this medicine should be used for as long as the prescriber considers it necessary. Posology For all indications a titration scheme for the initiation of therapy is described in Table 1, which is recommended for adults and adolescents aged 12 years and above.

Dosing instructions for children under 12 years of age are provided under a separate sub- heading later in this section. Table 1 DOSING CHART – INITIAL TITRATION Day 1 Day 2 Day 3 300 mg once a day 300 mg two times a day 300 mg three times a day Discontinuation of gabapentin In accordance with current clinical practice, if gabapentin has to be discontinued it is recommended this should be done gradually over a minimum of 1 week independent of the indication.

Epilepsy Epilepsy typically requires long-term therapy. Dosage is determined by the treating physician according to individual tolerance and efficacy.

Adults and adolescents:

In clinical trials, the effective dosing range was 900 to 3600 mg/day. Therapy may be initiated by titrating the dose as described in Table 1 or by administering 300 mg three times a day (TID) on Day 1. Thereafter, based on individual patient response and tolerability, the dose can be further increased in 300 mg/day increments every 2-3 days up to a maximum dose of 3600 mg/day.

Slower titration of gabapentin dosage may be appropriate for individual patients. The minimum time to reach a dose of 1800 mg/day is one week, to reach 2400 mg/day is a total of 2 weeks, and to reach 3600 mg/day is a total of 3 weeks.

Dosages up to 4800 mg/day have been well tolerated in long-term open-label clinical studies. The total daily dose should be divided in three single doses, the maximum time interval between the doses should not exceed 12 hours to prevent breakthrough convulsions.

Paediatric population (children aged 6 years and above):

The starting dose should range from 10 to 15 mg/kg/day and the effective dose is reached by upward titration over a period of approximately three days. The effective dose of gabapentin in children aged 6 years and older is 25 to 35 mg/kg/day.

Dosages up to 50 mg/kg/day have been well tolerated in a long-term clinical study. The total daily dose should be divided in three single doses, the maximum time interval between doses should not exceed 12 hours. It is not necessary to monitor gabapentin plasma concentrations to optimize gabapentin therapy.

Further, gabapentin may be used in combination with other antiepileptic medicinal products without concern for alteration of the plasma concentrations of gabapentin or serum concentrations of other antiepileptic medicinal products.

Peripheral neuropathic pain Adults The therapy may be initiated by titrating the dose as described in Table 1. Alternatively, the starting dose is 900 mg/day given as three equally divided doses. Thereafter, based on individual patient response and tolerability, the dose can be further increased in 300 mg/day increments every 2-3 days up to a maximum dose of 3600 mg/day.

Slower titration of gabapentin dosage may be appropriate for individual patients. The minimum time to reach a dose of 1800 mg/day is one week, to reach 2400 mg/day is a total of 2 weeks, and to reach 3600 mg/day is a total of 3 weeks.

In the treatment of peripheral neuropathic pain such as painful diabetic neuropathy and post-herpetic neuralgia, efficacy and safety have not been examined in clinical studies for treatment periods longer than 5 months. If a patient requires dosing longer than 5 months for the treatment of peripheral neuropathic pain, the treating physician should assess the patient’s clinical status and determine the need for additional therapy.

, the dose should be titrated more slowly, either by using smaller dosage strengths or longer intervals between dosage increases. Use in elderly patients (over 65 years of age) Elderly patients may require dosage adjustment because of declining renal function with age (see Table 2).

Somnolence, peripheral oedema and asthenia may be more frequent in elderly patients. Use in patients with renal impairment Dosage adjustment is recommended in patients with compromised renal function as described in Table 2 and/or those undergoing haemodialysis.

Gabapentin 100 mg capsules can be used to follow dosing recommendations for patients with renal insufficiency. Table 2 Dosage of Gabapentin in Adults Based on Renal Function Creatinine Clearance (ml/min) Total Daily Dosea (mg/day) ≤ 80 900-3600 50-79 600-1800 30-49 300-900 15-29 150b-600 <15c 150b-300 a Total daily dose should be administered as three divided doses.

Reduced dosages are for patients with renal impairment (creatinine clearance < 79 ml/min). b To be administered as 300 mg every other day. 5 ml/min should receive one-half the daily dose that patients with a creatinine clearance of 15 ml/min receive).

Use in patients undergoing haemodialysis For anuric patients undergoing haemodialysis who have never received gabapentin, a loading dose of 300 to 400 mg, then 200 to 300 mg of gabapentin following each 4 hours of haemodialysis, is recommended.

On dialysis-free days, there should be no treatment with gabapentin. For renally impaired patients undergoing haemodialysis, the maintenance dose of gabapentin should be based on the dosing recommendations found in Table 2. In addition to the […]

The adverse reactions observed during clinical studies conducted in epilepsy (adjunctive and monotherapy) and neuropathic pain have been provided in a single list below by class and frequency: very common (≥ 1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (< 1/10000) Where an adverse reaction was seen at different frequencies in clinical studies, it was assigned to the highest frequency reported.

Additional reactions reported from post-marketing experience are included as frequency Not known (cannot be estimated from the available data) in italics in the list below. Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.

g. g. 4), erythema multiforme, angioedema, alopecia, Musculoskeletal and connective tissue disorders Common arthralgia, myalgia, back pain, twitching Not known rhabdomyolysis, myoclonus, Exacerbation of myasthenia gravis Renal and urinary disorders Not known acute renal failure, incontinence Reproductive system and breast disorders Common impotence Not known breast hypertrophy, gynaecomastia, sexual dysfunction (including changes in libido, ejaculation disorders and anorgasmia) General disorders and administration site conditions Very Common fatigue, fever Common peripheral oedema, abnormal gait, asthenia, pain, malaise, flu syndrome Uncommon generalized oedema Not known withdrawal reactions*, chest pain.

Sudden unexplained deaths have been reported where a causal relationship to treatment with gabapentin has not been established Investigations Common WBC (white blood cell count) decreased, weight gain Uncommon elevated liver function tests SGOT (AST), SGPT (ALT) and bilirubin Not known blood creatine phosphokinase increased Injury, and poisoning Common accidental injury, fracture, abrasion Uncommon fall Description under the ADR table: * After discontinuation or dose reduction of short-term and long-term treatment with gabapentin, withdrawal symptoms have been observed.

4).

General disorders and administration site conditions:

After discontinuation of short-term and long-term treatment with Gabapentinoids withdrawal symptoms have been observed. The following symptoms have been reported: insomnia, headache, nausea, anxiety, diarrhoea, flu syndrome, convulsions, nervousness, depression, suicidal ideation, pain, hyperhidrosis and dizziness.

These symptoms may indicate drug dependence. The patient should be informed about this at the start of the treatment. 4). Under treatment with gabapentin cases of acute pancreatitis were reported. 4). In patients on haemodialysis due to end-stage renal failure, myopathy with elevated creatine kinase levels has been reported.

Respiratory tract infections, otitis media, convulsions and bronchitis were reported only in clinical studies in children. Additionally, in clinical studies in children, aggressive behaviour and hyperkinesias were reported commonly.

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. uk/yellowcard or search […]

Myasthenia Gravis Gabapentin should be used with caution in patients with myasthenia gravis as postmarketing cases of exacerbation of myasthenia gravis have been reported with gabapentin. Anaphylaxis Gabapentin can cause anaphylaxis.

Signs and symptoms in reported cases have included difficulty breathing, swelling of the lips, throat, and tongue, and hypotension requiring emergency treatment. Patients should be instructed to discontinue gabapentin and seek immediate medical care should they experience signs or symptoms of anaphylaxis.

Suicidal ideation and behaviour Suicidal ideation and behaviour have been reported in patients treated with anti- epileptic agents in several indications. A meta-analysis of randomised placebo controlled trials of anti-epileptic drugs has also shown a small increased risk of suicidal ideation and behaviour.

The mechanism of this risk is not known. 8). Patients should be monitored for signs of suicidal ideation and behaviour and appropriate treatment should be considered. 8). 2). As with other antiepileptic medicinal products, some patients may experience an increase in seizure frequency or the onset of new types of seizures with gabapentin.

As with other antiepileptics, attempts to withdraw concomitant anti-epileptics in treatment refractive patients on more than one antiepileptic, in order to reach gabapentin monotherapy have a low success rate. Gabapentin is not considered effective against primary generalized seizures such as absences and may aggravate these seizures in some patients.

Therefore, gabapentin should be used with caution in patients with mixed seizures including absences. Gabapentin treatment has been associated with dizziness and somnolence, which could increase the occurrence of accidental injury (fall) in the elderly population.

There have also been postmarketing reports of loss of consciousness, confusion, and mental impairment. Therefore, patients should be advised to exercise caution until they are familiar with the potential effects of the medicinal product.

Concomitant use with opioids Patients who require concomitant treatment with opioids should be carefully observed for signs of central nervous system (CNS) depression, such as somnolence, sedation and respiratory depression. Patients who use gabapentin and morphine concomitantly may experience increases in gabapentin concentrations.

5). Use in elderly patients (over 65 years of age) No systematic studies in patients 65 years or older have been conducted with gabapentin. In one double blind study in patients with neuropathic pain, somnolence, peripheral oedema and asthenia occurred in a somewhat higher percentage in patients aged 65 years or above, than in younger patients.

Apart from these findings, clinical investigations in this age group do not indicate an adverse event profile different from that observed in younger patients. Paediatric population The effects of long-term (greater than 36 weeks) gabapentin therapy on learning, intelligence, and development in children and adolescents have not been adequately studied.

The benefits of prolonged therapy must therefore be weighed against the potential risks of such therapy. Drug dependence, tolerance and potential for abuse Drug addiction comprises behavioural, cognitive and physiological phenomena that may include a strong desire to take the drug, difficulties in controlling drug use and possible tolerance or physical dependence.

Physical dependence is a state that develops as a result of physiological adaptation in response to repeated drug use, which manifests as withdrawal signs and symptoms after abrupt discontinuation or a significant dose reduction of a drug.

Addiction and dependence are related but distinct presentations and in discussing these themes, terminology that apportion blame to the individual should be avoided. For all patients, prolonged use of this product may lead to drug dependence and addiction but can occur with short-term use at recommended therapeutic doses.

, major depression). Additional support and monitoring may be necessary when prescribing for patients at risk of drug misuse. A comprehensive patient history should be taken to document concomitant medications, including over-the-counter medicines and medicines obtained on-line, and past and present medical and psychiatric conditions.

Patients may find that treatment is less effective with chronic use and express a need to increase the dose to obtain the same level of symptom control as initially experienced. Patients may also supplement their treatment with additional medications to achieve the same effect.

These could be signs that the patient is developing tolerance. The risks of developing tolerance should be explained to the patient. Overuse or misuse may result in overdose and/or death. It is important that patients only use medicines that are prescribed for them at the dose they have been prescribed and do not give this medicine to anyone else.

Patients should be closely monitored for […]

1.