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Domperidone 10mg Film-Coated Tablets

Last Updated on eMC 11-Sep-2013 View changes  | Wockhardt UK Ltd Contact details

Safety Alert - Changes to indications, contraindications and dosage

In May 2014, the MHRA issued the following information:

Domperidone (Motilium) is associated with a small increased risk of serious cardiac side effects. Its use is now restricted to the relief of nausea and vomiting and the dosage and duration of use have been reduced. It should no longer be used for the treatment of bloating and heartburn. Domperidone is now contraindicated in those with underlying cardiac conditions and other risk factors (see below). Patients with these conditions and patients receiving long-term treatment with domperidone should be reassessed at a routine appointment, in light of the new advice

Further information is available on the MHRA website

AnĀ Information sheet for patients has also been issued

1. Name of the medicinal product

Domperidone 10mg Film-Coated Tablets

2. Qualitative and quantitative composition

Each tablet contains 10mg domperidone (as domperidone maleate)

For excipients see 6.1

3. Pharmaceutical form

Film coated tablets

Domperidone Tablets 10mg are white, circular, film coated tablets marked DM on one face, 10 on the reverse.

4. Clinical particulars
4.1 Therapeutic indications

Adults: The relief of the symptoms of nausea and vomiting, epigastric sense of fullness, upper abdominal discomfort and regurgitation of gastric contents.

Children: The relief of symptoms of nausea and vomiting

4.2 Posology and method of administration

For oral administration.

It is recommended to take oral domperidone tablets before meals. If taken after meals, absorption of the drug is somewhat delayed.

The initial duration of treatment is four weeks. Patients should be re-evaluated after four weeks and the need for continued treatment re-assessed.

Adults and adolescents (over 12 years and weighing 35kg or more)

One to two of the 10mg tablets three to four times per day with a maximum daily dose of 80mg.

Infants and Children

0.25 – 0.5mg/kg three to four times per day with a maximum daily dose of 2.4mg/kg (but do not exceed 80mg per day)

Tablets are unsuitable for use in children weighing less than 35 kg.

(See section 4.4)

4.3 Contraindications

Domperidone is contraindicated in the following situations:

Known hypersensitivity to domperidone or any of the excipients.

Prolactin-releasing pituitary tumour (prolactinoma.)

Domperidone should not be used when stimulation of gastric motility could be harmful: gastro-intestinal haemorrhage, mechanical obstruction or perforation.

4.4 Special warnings and precautions for use

Precautions for use

The film-coated tablets contain lactose and may be unsuitable for patients with lactose intolerance, galactosaemia or glucose/galactose malabsorption.

This medicinal product contains 0.97mmol (0.042mg) of sodium per tablet. To be taken into consideration by patients on a controlled sodium dose.

Use during lactation

The total amount of domperidone excreted in human breast milk is expected to be less than 7 micrograms per day at the highest recommended dosing regimen. It is not known whether this is harmful to the newborn. Therefore breast-feeding is not recommended for mothers who are taking domperidone.

Use in infants

Neurological side effects are rare (see "Undesirable effects" section). Since metabolic functions and the blood-brain barrier are not fully developed in the first months of life the risk of neurological side effects is higher in young children. Therefore, it is recommended that the dose be determined accurately and followed strictly in children.

Overdosing may cause extrapyramidal symptoms in children, but other causes should be taken into consideration.

Use in liver disorders

Since domperidone is highly metabolised in the liver, domperidone should be not be used in patients with hepatic impairment

Renal insufficiency

In patients with severe renal insufficiency (serum creatinine > 6 mg/100 mL, i.e. > 0.6 m mol/L) the elimination half-life of domperidone was increased from 7.4 to 20.8 hours, but plasma drug levels were lower than in healthy volunteers. Since very little unchanged drug is excreted via the kidneys, it is unlikely that the dose of a single administration needs to be adjusted in patients with renal insufficiency. However, on repeated administration, the dosing frequency should be reduced to once or twice daily depending on the severity of the impairment, and the dose may need to be reduced. Such patients on prolonged therapy should be reviewed regularly.

Cardiovascular effects:

Some epidemiological studies showed that domperidone may be associated with an increased risk of serious ventricular arrhythmias or sudden cardiac death (see section 4.8) The risk may be higher in patients older than 60 years and at daily doses of more than 30 mg. Domperidone should be used at the lowest effective dose in adults and children.

Use of Domperidone and other drugs which prolong QTc intervals requires that caution be exercised in patients who have existing prolongation of cardiac conduction intervals particularly QTc patients with significant electrolyte disturbances of underlying cardiac diseases such as congestive heart failure.

Use with Potent CYP3A4 Inhibitors

Co-administration with oral ketoconazole, erythromycin or other potent CYP3A4 inhibitors that prolong the QTc interval should be avoided. A slight increase of QT interval (mean less than 10msec) was reported in a drug-drug interaction study with oral ketoconazole. Even if the significance of this study is not fully clear, alternative therapeutic options should be considered if antifungal treatment is required. (See also section 4.5)

4.5 Interaction with other medicinal products and other forms of interaction

The main metabolic pathway of domperidone is through CYP3A4. In vitro data suggest that the concomitant use of drugs that significantly inhibit this enzyme may result in increased plasma levels of domperidone. Separate in vivo pharmacokinetic/pharmacodynamic interaction studies with oral ketoconazole or oral erythromycin in healthy subjects confirmed a marked inhibition of domperidone's CYP3A4 mediated first pass metabolism by ketoconazole.

With the combination of oral domperidone 10mg four times daily and ketoconazole 200mg twice daily, a mean QTc prolongation of 9.8 msec was seen over the observation period, with changes at individual time points ranging from 1.2 to 17.5 msec. With the combination of domperidone 10mg four times daily and oral erythromycin 500mg three times daily, mean QTc over the observation period was prolonged by 9.9 msec, with changes at individual time points ranging from 1.6 to 14.3 msec. Both the Cmax and the AUC of domperidone at steady state were increased approximately three-fold in each of these interaction studies. In these studies domperidone monotherapy at 10mg given orally four times daily resulted in increases in mean QTc of 1.6 msec (ketoconazole study) and 2.5 msec (erythromycin study), while ketoconazole monotherapy (200mg twice daily) and erythromycin monotherapy (500mg three times daily) led to increases in QTc of 3.8 and 4.9 msec, respectively, over the observation period.

A QT prolonging effect could not be detected when domperidone was given alone in patients with no co-morbidity, even at high oral doses (up to 160mg/day).

The results of this interaction study should be taken into account when prescribing domperidone concomitantly with strong CYP3A4 inhibitors: for example: ketoconazole, ritonavir and erythromycin (See also section 5.2).

Opioids may antagonise the effects of domperidone on gastric emptying.

4.6 Pregnancy and lactation

There are limited post-marketing data on the use of domperidone in pregnant women. A study in rats has shown reproductive toxicity at a high, maternally toxic dose. The potential risk for humans is unknown. Therefore, domperidone should only be used during pregnancy when justified by the anticipated therapeutic benefit.

The drug is excreted in breast milk of lactating rats (mostly as metabolites: peak concentration of 40 and 800ng/ml after oral and i.v administration of 2.5mg/kg respectively). Domperidone concentrations in breast milk of lactating women are 10 to 50% of the corresponding plasma concentrations and expected not to exceed 10ng/ml. The total amount of domperidone excreted in human breast milk is expected to be less than 7micrograms per day at the highest recommended dosing regimen. It is not known whether this is harmful to the newborn. Therefore breast-feeding is not recommended for mothers who are taking domperidone.

4.7 Effects on ability to drive and use machines

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

4.8 Undesirable effects

The adverse drug reactions are ranked below by frequency, using the following convention: very common (>1/10), common (>1/100, to <1/10); uncommon (> 1/1,000, to <1/100); rare (>1/10,000, to <1/1,000); very rare (<1/10,000), not known (cannot be estimated from available data).

• Immune System Disorder: Very rare; Allergic reaction, including anaphylaxis, anaphylactic shock, anaphylactic reaction and angiodema

• Endocrine disorder: Rare; increased prolactin levels

• Psychiatric system disorders: Very rare: agitation, nervousness.

• Nervous system disorders: Very rare; extrapyramidal side effects, convulsion, somnolence, headache, Not known; dystonia

• Eye disorders: Not known; Oculogyric crisis

• Cardiac disorders: Not known; Prolongation of QT interval; Not known; Ventricular arrhythmias or sudden cardiac death also occur, (see section 4.4 Special warnings and precautions for use). Torsades de Pointes have been reported with intravenouss domperidone, however, the possibility of this risk should be considered with oral forms of domperidone.

• Gastro-intestinal disorders: Rare gastro-intestinal disorders including very rare transient intestinal cramps, very rare; diarrhoea

• Skin and subcutaneous tissue disorders: Very rare; urticaria, pruritus, rashes

• Reproductive system and breast disorders: Uncommon: breast pain, Rare;galactorrhoea, gynaecomastia, amenorrhoea, Not known; reduced libido.

• Investigations: very rare: liver function test abnormal.

As the hypophysis is outside the blood brain barrier, domperidone may cause an increase in prolactin levels. In rare cases this hyperprolactinaemia may lead to neuro-endrocrinological side effects such as galactorrhoea, gynaecomastia and amenorrhoea. Extrapyramidal side effects are exceptional in adults. These side effects reverse spontaneously and completely as soon as treatment is stopped.

Other central nervous system-related effects of convulsion, agitation, and somnolence also are very rare and primarily reported in infants and children.

4.9 Overdose

Symptoms

Overdose has been reported primarily in infants and children. Symptoms of overdosage may include agitation, altered consciousness, convulsion, disorientation, somnolence and extrapyramidal reactions.

Treatment

There is no specific antidote to domperidone, but in the event of overdose, gastric lavage as well as the administration of activated charcoal, may be useful. Close medical supervision and supportive therapy is recommended. Anticholinergic, anti-parkinson drugs may be helpful in controlling extrapyramidal reactions.

5. Pharmacological properties
5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Propulsives, ATC code: A03F A03

Domperidone is a dopamine antagonist with anti-emetic properties domperidone does not readily cross the blood-brain barrier. In domperidone users, especially in adults, extrapyramidal side effects are very rare, but domperidone promotes the release of prolactin from the pituitary. Its anti-emetic effect may be due to a combination of peripheral (gastrokinetic) effects and antagonism of dopamine receptors in the chemoreceptor trigger zone, which lies outside the blood-brain barrier in the area postrema. Animal studies, together with the low concentrations found in the brain, indicate a predominantly peripheral effect of domperidone on dopamine receptors.

Studies in man have shown oral domperidone to increase lower oesophageal pressure, improve antroduodenal motility and accelerate gastric emptying. There is no effect on gastric secretion.

5.2 Pharmacokinetic properties

Absorption

In fasting subjects, domperidone is rapidly absorbed after oral administration with peak plasma concentrations at 30 to 60 minutes. The low absolute bioavailability of oral domperidone (approximately 15%) is due to an extensive first-pass metabolism in the gut wall and liver. Although domperidone's bioavailability is enhanced in normal subjects when taken after a meal, patients with gastro-intestinal complaints should take domperidone 15-30 minutes before a meal. Reduced gastric acidity impairs the absorption of domperidone. Oral bioavailability is decreased by prior concomitant administration of cimetidine and sodium bicarbonate. The time of peak absorption is slightly delayed and the AUC somewhat increased when the oral drug is taken after a meal.

Distribution

Oral domperidone does not appear to accumulate or induce its own metabolism; a peak plasma level after 90 minutes of 21 ng/ml after two weeks oral administration of 30 mg per day was almost the same as that of 18 ng/ml after the first dose. Domperidone is 91-93% bound to plasma proteins. Distribution studies with radiolabelled drug in animals have shown wide tissue distribution, but low brain concentration. Small amounts of drug cross the placenta in rats.

Metabolism

Domperidone undergoes rapid and extensive hepatic metabolism by hydroxylation and N-dealkylation in vitro metabolism experiments with diagnostic inhibitors revealed that CYP3A4 is a major form of cytochrome P-450 involved in the N-dealkylation of domperidone whereas CYP3A4, CYP1A2 AND CYP2E1 are involved in domperidone aromatic hydroxylation.

Excretion

Urinary and faecal excretions amount to 31 and 66% of the oral dose respectively, The proportion of the drug excreted unchanged is small (10% of faecal excretion and approximately 1% of urinary excretion). The plasma half life after a single oral dose is 7-9 hours in healthy subjects but is prolonged in patients with severe renal insufficiency.

5.3 Preclinical safety data

Electrophysiological in vitro and in vivo studies indicate an overall moderate risk of domperidone to prolong the QT interval in humans. In in-vitro experiments on isolated cells transfected with HERG and on isolated guinea pig myocytes, ratios were about 10, based on IC50 values inhibiting currents through ion channels in comparison to the free plasma concentrations in humans after administration of the maximum daily dose of 20 mg (q.i.d.). However, safety margins in in-vitro experiments on isolated cardiac tissues and in in-vivo models (dog, guinea pig, rabbits sensitised for torsades de points) exceeded the free plasma concentrations in humans at maximum daily dose (20mg q.i.d.) by more than 50-fold. In the presence of inhibition of the metabolism via CYP3A4 free plasma concentrations of domperidone can rise up to 10- fold.

At a high, maternally toxic dose (more than 40 times the recommended human dose), teratogenic effects were seen in the rat. No teratogenicity was observed in mice and rabbits.

6. Pharmaceutical particulars
6.1 List of excipients

Lactose

Pregelatinised Maize Starch

Microcrystalline Cellulose

Sodium Starch Glycollate Type A

Magnesium Stearate

Tablet coating

Titanium dioxide (E171)

Hypromellose

Macrogol

6.2 Incompatibilities

Not applicable

6.3 Shelf life

Three years

6.4 Special precautions for storage

Do not store above 25°C. Store in the original container or package.

6.5 Nature and contents of container

Multiples of 10 or 14 tablets in blisters of PVC film/aluminium foil of the following sizes: 10,20,30,40,50,60,70,80,90,100 and 14,28,42,56,70,84,98,112.

Multiples of 10 or 14 tablets in polypropylene/polyethylene containers with tamper evident closures containing 10, 20, 30, 40, 50, 60, 70, 80, 90, 100 and 14, 28, 42, 56, 70, 84, 98, 112.

6.6 Special precautions for disposal and other handling

None

7. Marketing authorisation holder

Wockhardt UK Ltd

Ash Road North

Wrexham

LL13 9UF

UK

8. Marketing authorisation number(s)

PL 29831/0076

9. Date of first authorisation/renewal of the authorisation

15th October 2007

10. Date of revision of the text

22nd April 2013

Company contact details

Wockhardt UK Ltd

Company image
Address

Ash Road North, Wrexham Industrial Estate, Wrexham, LL13 9UF

Fax

+44 (0)1978 660 130

Telephone

+44 (0)1978 661 261

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Active ingredients

domperidone maleate

Legal categories

POM - Prescription Only Medicine

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