Boots Paracetamol 120 mg/5 ml Oral Suspension (P)

To relieve mild to moderate pain and to reduce fever in many conditions including headache, toothache, teething, feverishness, colds and influenza and following vaccination.

For oral use only.

It is important to shake the bottle for at least 10 seconds before use.

For other causes of pain and fever:

Elderly: In the elderly, the rate and extent of paracetamol absorption is normal but plasma half-life is longer and paracetamol clearance is lower than in young adults.

Hypersensitivity to paracetamol or any of the other ingredients.

Do not exceed the recommended dose. Taking more than the recommended dose may cause liver damage. In case of overdose get medical help straight away. Quick medical attention is critical for adults as well as children even if signs and symptoms are not noticed.

Talking this product with other paracetamol-containing medicines could lead to overdose and should therefore be avoided.

Caution in patients with severely impaired liver or kidney function. The hazards of overdose are greater in those with non-cirrhotic alcoholic liver disease. Chronic alcohol users should consult a doctor before use.

Cases of high anion gap metabolic acidosis (HAGMA) due to pyroglutamic acidosis have been reported in patients with severe illness such as severe renal impairment and sepsis, or in patients with malnutrition or other sources of glutathione deficiency (e.g. chronic alcoholism) who were treated with paracetamol at therapeutic dose for a prolonged period or a combination of paracetamol and flucloxacillin. If HAGMA due to pyroglutamic acidosis is suspected, prompt discontinuation of paracetamol and close monitoring is recommended. The measurement of urinary 5-oxoproline may be useful to identify pyroglutamic acidosis as the underlying cause of HAGMA in patients with multiple risk factors.

Glutathione deficiency can also increase the risk of hepatotoxicity with paracetamol use, even at therapeutic doses. Caution is advised for patients at risk of glutathione depletion (See section 4.9).

Hepatotoxicity at therapeutic dose

Cases of paracetamol induced hepatotoxicity, including fatal cases, have been reported in patients taking paracetamol at doses within the therapeutic range. These cases were reported in patients with one or more risk factors for hepatotoxicity including low body weight (adults <50 kg), renal and hepatic impairment, chronic alcoholism, concomitant intake of hepatotoxic drugs and in acute and chronic malnutrition (low reserves of hepatic glutathione). Paracetamol should be administered with caution to patients with these risk factors. Caution is also advised in patients on concomitant treatment with drugs that induce hepatic enzymes and in conditions which may predispose to glutathione deficiency (see section 4.9).

Dosage adjustment of paracetamol should be considered where there are risk factors for glutathione deficiency or hepatotoxicity and for those of low weight (for adults those weighing less than 50kg).

Sorbitol may cause gastrointestinal discomfort and have a mild laxative effect. Each 5 ml dose of this product contains 0.8 g of sorbitol. It has a calorific value of 2.6 kcal/g sorbitol.

This medicine contains 1.3 g maltitol in each 5 ml dose. Patients with rare hereditary problems of fructose intolerance should not take this medicine.

Methyl Parahydroxybenzoate (E218) may cause allergic reactions (possibly delayed). The colour carmoisine (E122) may cause allergic reactions.

This medicine contains less than 1 mmol sodium (23mg) per 5 ml dose, that is to say essentially 'sodium-free'.

This medicine contains 0.06 mg of benzyl alcohol in each 5 ml dose. Benzyl alcohol may cause allergic reactions. Do not use for more than a week in young children (less than 3 years old), unless advised by your doctor or pharmacist.

Ask your doctor or pharmacist for advice if you are pregnant or breastfeeding or have liver or kidney disease. This is because large amounts of benzyl alcohol can build-up in your body and may cause side effects (called “metabolic acidosis”).

This medicine contains 12 mg of propylene glycol in each 5 ml dose.

This medicine contains 11.5 mg benzoate salt in each 5 ml dose.

Very rare cases of serious skin reactions have been reported. Patients should be informed about the signs of serious skin reactions and use of the drug should be discontinued at the first appearance of skin rash or any other sign of hypersensitivity.

The labelling should contain the following statements:

Contains paracetamol.

Do not give anything else containing paracetamol while giving this medicine. Give this medicine to your child to swallow.

Do not give more medicine than the label tells you to. If your child does not get better talk to your doctor.

Always use the syringe supplied with the pack.

Do not give to babies less than 2 months of age.

Do not give if your child is between 2-3 months old and is taking this medicine for other causes of pain and fever and weighs less than 4 kg or was born before 37 weeks. For infants 2-3 months no more than 2 doses should be given.

Do not give more than 4 doses in any 24 hour period.

Leave at least 4 hours between doses.

Do not give this medicine to your child for more than 3 days without speaking to your doctor or pharmacist.

As with all medicines, if your child is currently taking any other medicine consult your doctor or pharmacist before using this product.

Keep all medicines out of the sight and reach of children.

Do not store above 25°C. Store in the original package. Keep the lid tightly closed.

Talk to a doctor at once if your child takes too much of this medicine, even if they seem well.

Never give more medicine than shown in the table.

Leaflet or combined label/leaflet:

Talk to a doctor at once if your child takes too much of this medicine, even if they seem well. This is because too much paracetamol can cause delayed, serious liver damage.

Don't give more than 4 times in any 24 hours.

Leave at least 4 hours between doses.

For the relief of fever after vaccination at 2, 3 and 4 months, if your baby still needs this medicine 2 days after receiving the vaccine talk to your doctor or pharmacist.

Very rare cases of serious skin reactions have been reported. Symptoms may include:

- Skin reddening

- Blisters

- Rash

If skin reactions occur or existing skin symptoms worsen, stop use and seek medical help right away.

Warnings related specifically to excipients in this formulation (see section 6.1)

This medicine contains 0.8 g sorbitol and 1.3 g maltitol per 5 ml spoonful. This provides 5 kcal per 5 ml spoonful. If your child has been told by a doctor that they have an intolerance to some sugars, contact their doctor before taking this medicinal product.

Methyl hydroxybenzoate (E218) may cause allergic reactions (possibly delayed).

The colour carmoisine (E122) may cause allergic reactions.

This medicine contains less than 1 mmol sodium (23mg) per 5 ml dose, that is to say essentially 'sodium-free'.

This medicine contains 0.06 mg of benzyl alcohol in each 5 ml dose. Benzyl alcohol may cause allergic reactions. Do not use for more than a week in young children (less than 3 years old), unless advised by your doctor or pharmacist.

Ask your doctor or pharmacist for advice if you are pregnant or breastfeeding, or have liver or kidney disease. This is because large amounts of benzyl alcohol can build-up in your body and may cause side effects (called “metabolic acidosis”).

This medicine contains 12 mg of propylene glycol in each 5 ml dose.

This medicine contains 11.5 mg benzoate salt in each 5 ml dose.

Drugs which induce hepatic microsomal enzymes

Metabolism of paracetamol possibly accelerated by carbamazepine, fosphenytoin, phenytoin, phenobarbital, primidone (also isolated reports of hepatotoxicity).

The speed of absorption of paracetamol may be increased by metoclopramide or domperidone and absorption reduced by colestyramine.

The anticoagulant effect of warfarin and other coumarins may be enhanced by prolonged regular use of paracetamol with increased risk of bleeding; occasional doses have no significant effect.

Patients who have taken barbiturates, tricyclic antidepressants and alcohol may show diminished ability to metabolise large doses of paracetamol, the plasma half-life of which can be prolonged.

Alcohol can increase the hepatotoxicity of paracetamol overdosage and may have contributed to the acute pancreatitis reported in one patient who had taken an overdose of paracetamol.

Chronic ingestion of anticonvulsants or oral steroid contraceptives induce liver enzymes and may prevent attainment of therapeutic paracetamol levels by increasing first pass metabolism or clearance.

Caution should be taken when paracetamol is used concomitantly with flucloxacillin as concurrent intake has been associated with high anion gap metabolic acidosis due to pyroglutamic acidosis, especially in patients with risk factors (see section 4.4).

Pregnancy

A large amount of data on pregnant women indicate neither malformative, nor feto/neonatal toxicity. Epidemiological studies on neurodevelopment in children exposed to paracetamol in utero show inconclusive results. If clinically needed, paracetamol can be used during pregnancy however it should be used at the lowest effective dose for the shortest possible time and at the lowest possible frequency.

When given to the mother in therapeutic doses (1 g single dose), paracetamol crosses the placenta into foetal circulation as early as 30 minutes after ingestion and is metabolised in the foetus by conjugation with sulfate and increasingly with glutathione.

Breast-feeding

Paracetamol is excreted in breast milk but not in a clinically significant amount. Available published data do not contraindicate breast feeding.

Fertility

There is no information relating to the effects of this medicine on fertility.

No adverse effects known.

Adverse drug reactions (ADRs) identified during clinical trials and post-marketing experience with paracetamol are listed below by System Organ Class (SOC).

The frequencies are defined according to the following convention:

ADRs are presented by frequency category based on 1) incidence in adequately designed clinical trials or epidemiology studies, if available or 2) when incidence is unavailable, frequency category is listed as not known.

¹ Reported following paracetamol use, but not necessarily causally related to the drug

² Chronic hepatic necrosis has been reported in a patient who took daily therapeutic doses of paracetamol for about a year

³ Reported after prolonged administration

⁴ Low level transaminase elevations may occur in some patients taking therapeutic doses of paracetamol; these elevations are not accompanied with liver failure and usually resolve with continued therapy or discontinuation of paracetamol.

⁵Cases of high anion gap metabolic acidosis due to pyroglutamic acidosis have been observed in patients with risk factors using paracetamol (see section 4.4). Pyroglutamic acidosis may occur as a consequence of low glutathione levels in these patients.

Very rare cases of serious skin reactions have been reported.

Chronic hepatic necrosis has been reported in a patient who took daily therapeutic doses of paracetamol for about a year and liver damage has been reported after daily ingestion of excessive amounts for shorter periods. A review of a group of patients with chronic active hepatitis failed to reveal differences in the abnormalities of liver function in those who were long-term users of paracetamol nor was the control of the disease improved after paracetamol withdrawal.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

Liver damage is possible in patients who have taken more than recommended doses of paracetamol. It is considered that excess quantities of a toxic metabolite (usually adequately detoxified by glutathione when normal doses of paracetamol are ingested) become irreversibly bound to liver tissue.

Ingestion of paracetamol at therapeutic doses may lead to liver damage if the patient has risk factors (see below).

Risk Factors:

If the patient

a) Is on long term treatment with carbamazepine, phenobarbitone, phenytoin, primidone, rifampicin, St John's Wort or other drugs that induce liver enzymes.

or

b) Regularly consumes ethanol in excess of recommended amounts.

or

c) Is likely to be glutathione deplete e.g diet (malnutrition, fasting, dietary restrictions, eating disorders and starvation), catabolic states (sepsis), cachexia and chronic illness (cystic fibrosis, liver disease, HIV and muscular dystrophy).

Symptoms

Symptoms of paracetamol overdosage in first 24 hours are pallor, nausea, hyperhidrosis, malaise, vomiting, anorexia and abdominal pain. Liver damage may become apparent 12 to 48 hours after ingestion. This may include hepatomegaly, liver tenderness, jaundice, acute hepatic failure and hepatic necrosis. Abnormalities of glucose metabolism and metabolic acidosis may occur. In severe poisoning, hepatic failure may progress to encephalopathy, haemorrhage, hypoglycaemia, cerebral oedema, and death. Acute renal failure with acute tubular necrosis, strongly suggested by loin pain, haematuria and proteinuria, may develop even in the absence of severe liver damage. Cardiac arrhythmias and pancreatitis have been reported.

Haemolytic anaemia (in patients with glucose-6-phosphate dehydrogenase [G6PD] deficiency): Haemolysis has been reported in patients with G6PD deficiency, with use of paracetamol in overdose.

Management

Immediate treatment is essential in the management of paracetamol overdose. Despite a lack of significant early symptoms, patients should be referred to hospital urgently for immediate medical attention. Symptoms may be limited to nausea or vomiting and may not reflect the severity of overdose or the risk of organ damage. Management should be in accordance with established treatment guidelines, see BNF overdose section.

Treatment with activated charcoal should be considered if the overdose has been taken within 1 hour. Plasma paracetamol concentration should be measured at 4 hours or later after ingestion (earlier concentrations are unreliable). Treatment with N-acetylcystine may be used up to 24 hours after ingestion of paracetamol, however, the maximum protective effect is obtained up to 8 hours post-ingestion. If required the patient should be given intravenous N-acetylcysteine, in line with the established dosage schedule. If vomiting is not a problem, oral methionine may be a suitable alternative for remote areas, outside hospital. Management of patients who present with serious hepatic dysfunction beyond 24h from ingestion should be discussed with the NPIS or a liver unit.

Paracetamol is a peripherally acting analgesic with antipyretic activity.

Paracetamol is readily absorbed from the gastrointestinal tract with peak plasma concentrations occurring about 30 minutes to 2 hours after ingestion. Paracetamol is metabolised in the liver and excreted in the urine mainly as the glucuronide and sulphate conjugates, with about 10% as glutathione conjugates. Less than 5% is excreted as unchanged paracetamol. Plasma protein binding is negligible at usual therapeutic concentrations, although this is dose dependent. The plasma elimination half life varies from about one to four hours.

Conventional studies using the currently accepted standards for the evaluation of toxicity to reproduction and development are not available.

Sorbitol solution (E420)

Glycerol (E422)

Maltitol liquid (E965)

Microcrystalline cellulose (E460)

Sodium carboxymethylcellulose (E468)

Hydroxyethylcellulose (E1525)

Methyl parahydroxybenzoate (E218)

Strawberry flavour (ABJHP) (containing benzyl alcohol (E1519), ethyl benzoate, Propylene glycol (E1520))

Strawberry flavour (L-125660) (containing propylene glycol (E1520))

Sugar flavour (S11260) (containing propylene glycol (E1520))

Carmoisine edicol (E122)

Purified water

Not applicable

24 months

Do not store above 25°C.

120ml, 130ml, 140ml, 150ml, 200ml, 240ml, 250ml 300ml amber PET bottle with polypropylene child resistant closure with expanded polyethylene liner or polyethylene plug.

Syringe composed of a natural polypropylene barrel and a polyethylene pigmented white plunger.

Not all pack sizes may be marketed.

Not applicable.