Lioresal ® Liquid

The active ingredient is: β-(Aminomethyl)-p-chlorohydrocinnamic acid (= baclofen), a racemic mixture of the R,(-) and S, (+) isomers.

The liquid contains 5mg/5ml baclofen Ph. Eur.

For excipients see section 6.1 List of excipients

Liquid

Lioresal is indicated for the relief of spasticity of voluntary muscle resulting from such disorders as: multiple sclerosis, other spinal lesions, e.g. tumours of the spinal cord, syringomyelia, motor neurone disease, transverse myelitis, traumatic partial section of the cord.

Lioresal is also indicated in adults and children for the relief of spasticity of voluntary muscle arising from e.g. cerebrovascular accidents, cerebral palsy, meningitis, traumatic head injury.

Patient selection is important when initiating Lioresal therapy; it is likely to be of most benefit in patients whose spasticity constitutes a handicap to activities and/or physiotherapy. Treatment should not be commenced until the spastic state has become stabilised.

Paediatric population

Lioresal is indicated in patients 0 to <18 years for the symptomatic treatment of spasticity of cerebral origin, especially where due to infantile cerebral palsy, as well as following cerebrovascular accidents or in the presence of neoplastic or degenerative brain disease.

Lioresal is also indicated for the symptomatic treatment of muscle spasms occurring in spinal cord diseases of infectious, degenerative, traumatic, neoplastic, or unknown origin such as multiple sclerosis, spastic spinal paralysis, amyotrophic lateral sclerosis, syringomyelia, transverse myelitis, traumatic paraplegia or paraparesis, and compression of the spinal cord.

Lioresal is given orally in either tablet or liquid form. These two formulations are bioequivalent. The liquid may be particularly suitable for children or those adults who are unable to take tablets. Dosage titration can be more precisely managed with the liquid. The lowest dose compatible with an optimal response is recommended.

Before starting treatment with Lioresal it is prudent to realistically assess the overall extent of clinical improvement that the patient may be expected to achieve. Careful titration of dosage is essential (particularly in the elderly) until the patient is stabilised. If too high a dose is initiated or if the dosage is increased too rapidly side effects may occur. This is particularly relevant if the patient is ambulant in order to minimise muscle weakness in the unaffected limbs or where spasticity is necessary for support.

Once the maximum recommended dose has been reached, if the therapeutic effect is not apparent within 6 weeks a decision whether to continue with Lioresal should be taken.

Adults: Treatment should be started with a dosage of 15 mg daily, preferably in divided doses. The following gradually increasing dosage regimen is suggested, but should be adjusted to suit individual patient requirements.

5mg three times a day for three days

10mg three times a day for three days

15mg three times a day for three days

20mg three times a day for three days

Satisfactory control of symptoms is usually obtained with doses of up to 60mg daily, but a careful adjustment is often necessary to meet the requirements of each individual patient.

The dose may be increased slowly if required, but a maximum daily dose of more than 100mg is not advised unless the patient is in hospital under careful medical supervision. Small frequent dosage may prove better in some cases than larger spaced doses.

Also some patients benefit from the use of Lioresal only at night to counteract painful flexor spasm. Similarly a single dose given approximately 1 hour prior to performance of specific tasks such as washing, dressing, shaving, physiotherapy, will often improve mobility.

Elderly: Elderly patients may be more susceptible to side effects, particularly in the early stages of introducing Lioresal. Small doses should therefore be used at the start of treatment, the dose being titrated gradually against the response, under careful supervision. There is no evidence that the eventual average maximum dose differs from that in younger patients.

Paediatric population (0 to < 18 years): Treatment should usually be started with a very low dose (corresponding to approximately 0.3 mg/kg a day), in 2-4 divided doses, preferably in 4 divided doses. The dosage should be cautiously raised at about 1 week intervals, until it becomes sufficient for the child's individual requirements. The usual daily dosage for maintenance therapy ranges between 0.75 and 2mg/kg body weight. The total daily dose should not exceed a maximum of 40mg/day in children below 8 years of age. In children over 8 years of age, a maximum daily dosage of 60mg/day may be given.

Lioresal tablets are not suitable for use in children below 33 kg body weight.

Patients with impaired renal function: In patients with impaired renal function or undergoing chronic haemodialysis, a particularly low dosage of Lioresal should be selected i.e. approx. 5mg daily.

Lioresal should only be administered to end stage renal failure patients when benefit outweighs risk. These patients should be closely monitored for prompt diagnosis of early signs and/or symptoms of toxicity (e.g. somnolence, lethargy) (see section 4.4 Special warnings and precautions for use and section 4.9 Overdose).

Patients with spastic states of cerebral origin: Unwanted effects are more likely to occur in these patients. It is therefore recommended that a very cautious dosage schedule be adopted and that patients be kept under appropriate surveillance.

Hypersensitivity to baclofen or to any of the excipients, peptic ulceration.

Psychiatric and nervous system disorders

Psychotic disorders, schizophrenia, depressive or manic disorders, confusional states or Parkinson's disease may be exacerbated by treatment with Lioresal. Patients suffering from these conditions should therefore be treated cautiously and kept under close surveillance.

Epilepsy

Lioresal may also exacerbate epileptic manifestations but can be employed provided appropriate supervision and adequate anticonvulsive therapy are maintained.

Others

Lioresal should be used with extreme care in patients already receiving antihypertensive therapy, (see Section 4.5).

Lioresal should be used with caution in patients suffering from cerebrovascular accidents or from respiratory or hepatic impairment.

Renal impairment

Signs of overdose have been observed in patients with renal impairment taking oral Lioresal at doses of more than 5mg per day. Lioresal should be used with caution in patients with renal insufficiency and should only be administered to patients with end-stage renal failure (CKD stage 5, GFR < 15mL/min) when benefit outweighs risk (see Section 4.2).

Cases of baclofen toxicity have been reported in patients with acute renal failure (see Section 4.9).

Particular caution is required when combining Lioresal to drugs or medicinal products that can significantly affect renal function. Renal function should be closely monitored and Lioresal daily dosage adjusted accordingly to prevent baclofen toxicity.

Besides discontinuing treatment, unscheduled haemodialysis might be considered as a treatment alternative in patients with severe baclofen toxicity. Haemodialysis effectively removes baclofen from the body, alleviates clinical symptoms of overdose and shortens the recovery time in these patients.

Urinary disorders

Under treatment with Lioresal neurogenic disturbances affecting emptying of the bladder may show an improvement. In patients with pre-existing sphincter hypertonia, acute retention of urine may occur; the drug should be used with caution in such cases.

Laboratory tests

In rare instances elevated AST, alkaline phosphatase and glucose levels in serum have been recorded. Appropriate laboratory tests should be performed in patients with liver diseases or diabetes mellitus in order to ensure that no drug induced changes in these underlying diseases have occurred.

Excipients

Lioresal syrup contains methyl hydroxybenzoate and propyl hydroxybenzoate, which may cause allergic reactions (possibly delayed). Lioresal syrup contains sorbitol. Patients with rare hereditary problems of fructose intolerance should not take this medicine. Lioresal syrup also contains 1.6 mg of sodium per 1 mL of syrup.

Abrupt withdrawal:

Anxiety and confusional states, hallucinations, psychotic, manic or paranoid states, convulsions (status epilepticus), dyskinesia, tachycardia, hyperthermia and as rebound phenomenon temporary aggravation of spasticity have been reported with abrupt withdrawal of Lioresal, especially after long term medication.

Neonatal convulsions have been reported after intrauterine exposure to oral Lioresal (see Section 4.6).

Treatment should always, (unless serious adverse effects occur), therefore be gradually discontinued by successively reducing the dosage over a period of about 1-2 weeks.

There is very limited clinical data on the use of Lioresal in children under the age of one year. Use in this patient population should be based on the physician's consideration of individual benefit and risk of therapy.

Where Lioresal is taken concomitantly with other drugs acting on the CNS, with synthetic opiates or with alcohol, increased sedation may occur.

The risk of respiratory depression is also increased. Careful monitoring of respiratory and cardiovascular functions is essential especially in patients with cardiopulmonary disease and respiratory muscle weakness.

During concurrent treatment with tricyclic antidepressants, the effect of Lioresal may be potentiated, resulting in pronounced muscular hypotonia.

Since concomitant treatment with Lioresal and anti-hypertensives is likely to increase the fall in blood pressure, the dosage of antihypertensive medication should be adjusted accordingly. Hypotension has been reported in one patient receiving morphine and intrathecal baclofen.

In patients with Parkinson's disease receiving treatment with Lioresal and levodopa plus carbidopa, there have been reports of mental confusion, hallucinations, nausea and agitation.

Drugs or medicinal products that can significantly affect renal function may reduce baclofen excretion leading to toxic effects (see Section 4.4).

During pregnancy, especially in the first 3 months, Lioresal should only be employed if its use is of vital necessity. The benefits of the treatment for the mother must be carefully weighed against the possible risks for the child. Baclofen crosses the placental barrier.

One case of suspected withdrawal reaction (generalised convulsions) has been reported in a week-old infant whose mother had taken oral baclofen 80 mg daily throughout her pregnancy. The convulsions, which were refractory to standard anticonvulsant treatment, ceased within 30 minutes of giving baclofen to the infant.

In mothers taking Lioresal in therapeutic doses, the active substance passes into the breast milk, but in quantities so small that no undesirable effects on the infant are to be expected.

Lioresal may be associated with dizziness, sedation, somnolence and visual disturbances (See section 4.8 Undesirable effects) which may impair the patient's reaction. Patients experiencing these adverse reactions should be advised to refrain from driving or using machines.

Adverse reactions (Table 1) are ranked under heading of frequency, the most frequent first, using the following convention: very common ( 1/10); common ( 1/100, < 1/10); uncommon ( 1/1,000, < 1/100); rare ( 1/10,000, < 1/1,000) very rare (< 1/10,000) and Not known (cannot be estimated from the available data).

Unwanted effects occur mainly at the start of treatment (e.g. sedation, somnolence and nausea) if the dosage is raised too rapidly, if large doses are employed, or in elderly patients. They are often transitory and can be attenuated or eliminated by reducing the dosage; they are seldom severe enough to necessitate withdrawal of the medication.

Should nausea persist following a reduction in dosage, it is recommended that Lioresal be ingested with food or a milk beverage.

In patients with a case history of psychiatric illness or with cerebrovascular disorders (e.g. stroke) as well as in elderly patients, adverse reactions may assume a more serious form.

Lowering of the convulsion threshold and convulsions may occur, particularly in epileptic patients.

Table 1

Certain patients have shown increased spasticity as a paradoxical reaction to the medication.

An undesirable degree of muscular hypotonia - making it more difficult for patients to walk or fend for themselves - may occur and can usually be relieved by re-adjusting the dosage (i.e. by reducing the doses given during the day and possibly increasing the evening dose).

Symptoms: Prominent features are signs of central nervous depression: drowsiness, impairment of consciousness, respiratory depression, coma. Also liable to occur are: confusion, hallucinations, agitation, accommodation disorders, absent pupillary reflex, generalised muscular hypotonia, myoclonia, hyporeflexia or areflexia, convulsions, EEG changes (burst suppression pattern and triphasic waves), peripheral vasodilatation, hypotension or hypertension, bradycardia, tachycardia or cardiac arrhythmias, hypothermia, nausea, vomiting, diarrhoea, hypersalivation, elevated LDH, AST and ALP values. Patients with renal impairment can develop signs of overdose even on low doses of oral Lioresal (see Section 4.2 and Section 4.4).

A deterioration in the condition may occur if various substances or drugs acting on the central nervous system (e.g. alcohol, diazepam, tricyclic antidepressants) have been taken at the same time.

Treatment: No specific antidote is known.

Supportive measures and symptomatic treatment should be given for complications such as hypotension, hypertension, convulsions, respiratory or cardiovascular depression.

After ingestion of a potentially toxic amount, activated charcoal should be considered. In the early period after ingestion charcoal should be considered in adults who ingested more than 100mg baclofen within 1 hour, and in children who have ingested more than 5mg/kg baclofen within 1 hour. Gastric decontamination (e.g. gastric lavage) should be considered in individual cases, especially in the early period (60 minutes) after ingestion of a potentially life-threatening overdose. Comatose or convulsing patients should be intubated prior to the initiation of gastric decontamination.

Since the drug is excreted chiefly via the kidneys, generous quantities of fluid should be given, possibly together with a diuretic. Haemodialysis (sometimes unscheduled) may be useful in severe poisoning associated with renal failure (see Section 4.4). In the event of convulsions diazepam should be administered cautiously i.v.

Pharmacotherapeutic group: Antispastic with spinal site attack, ATC code: M03B X01

Lioresal is an antispastic agent acting at the spinal level. A gamma-aminobutyric acid (GABA) derivative, Lioresal is chemically unrelated to other antispastic agents.

Lioresal depresses monosynaptic and polysynaptic reflex transmission, probably by stimulating the GABA_B receptors, this stimulation in turn inhibiting the release of the excitatory amino acids glutamate and aspartate. Neuromuscular transmission is unaffected by Lioresal.

The major benefits of Lioresal stem from its ability to reduce painful flexor spasms and spontaneous clonus thereby facilitating the mobility of the patient, increasing his independence and helping rehabilitation.

Lioresal also exerts an antinociceptive effect. General well being is often improved and sedation is less often a problem than with centrally acting drugs.

Baclofen stimulates gastric acid secretion.

Absorption: Lioresal (baclofen) is rapidly and completely absorbed from the gastro-intestinal tract. No significant difference between the liquid and tablet formulations is observed in respect of t_max, c_max and bioavailability. Following oral administration of single doses (10-30mg) peak plasma concentrations are recorded after 0.5 to 1.5 hours and areas under the serum concentration curves are proportional to the dose.

Distribution: The volume of distribution of baclofen is 0.7 l/kg and the protein binding rate is approximately 30%. In cerebrospinal fluid active substance concentrations are approximately 8.5 times lower than in the plasma.

Biotransformation: Baclofen is metabolised to only a minor extent. Deamination yields the main metabolite, β-(p-chlorophenyl)-4-hydroxybutyric acid, which is pharmacologically inactive.

Elimination/excretion: The plasma elimination half-life of baclofen averages 3 to 4 hours. The serum protein binding rate is approximately 30%.

Baclofen is eliminated largely in unchanged form. Within 72 hours, about 75% of the dose is excreted via the kidneys with about 5% of this amount as metabolites.

Elderly: The pharmacokinetics of baclofen in elderly patients are virtually the same as in young subjects. The peak plasma concentrations of baclofen in elderly patients are slightly lower and occur later than in healthy young subjects but the AUCs are similar in the two groups.

Baclofen increases the incidence of omphaloceles (ventral hernias) in the foetuses of rats given approximately 13 times the maximum oral dose (on a mg/kg basis) recommended for human use. This was not seen in mice or rabbits.

An apparently dose related increase in the incidence of ovarian cysts, and a less marked increase in enlarged and/or haemorrhagic adrenals have been observed in female rats treated for 2 years. The clinical relevance of these findings is not known.

Experimental evidence to date suggests that baclofen does not possess either carcinogenic or mutagenic properties.

Methyl hydroxybenzoate; propyl hydroxybenzoate; raspberry flavour; carmellose sodium, sorbitol; purified water.

None known.

3 years

Protect from light. Store below 25°C. Do not refrigerate.

Dilution: Lioresal liquid may be diluted with Purified Water BP and stored at room temperature for up to 14 days.

Liquid 5mg/5ml: clear, very slightly yellow solution with a raspberry flavour.

Bottles of 300ml with child proof closures.

There is no specific instruction for use/handling.

Novartis Pharmaceuticals UK Ltd,

Trading as:

Ciba Laboratories,

Frimley Business Park

Frimley

Camberley

Surrey

GU16 7SR

PL 00101 / 0503

1 April 2001

17 August 2011

POM