This information is intended for use by health professionals

1. Name of the medicinal product

DIAMOX* 250mg Tablets

Acetazolamide Mercury Pharma 250mg Tablets

2. Qualitative and quantitative composition

Each tablet contains 250mg acetazolamide BP.

For excipients see 6.1.

3. Pharmaceutical form

Tablet.

Round, convex, white tablets engraved with “FW 147” on one side and cored in quarters on the other.

4. Clinical particulars
4.1 Therapeutic indications

DIAMOX Tablets are for oral administration.

Acteazolamide is an enzyme inhibitor which acts specifically on carbonic anhydrase. It is indicated in the treatment of:

i) Glaucoma: DIAMOX Tablets is useful in glaucoma (chronic simple (open angle) glaucoma, secondary glaucoma, and perioperatively in acute angle closure glaucoma where delay of surgery is desired in order to lower intraocular pressure) because it acts on inflow, decreasing the amount of aqueous secretion.

ii) Abnormal retention of fluids: DIAMOX Tablets is a diuretic whose effect is due to the effect on the reversible hydration of carbon dioxide and dehydration of carbonic acid reaction in the kidney. The result is renal loss of HC03- ion which carries out sodium, water and potassium. DIAMOX Tablets can be used in conjunction with other diuretics when effects on several segments of the nepbron are desirable in the treatment of fluid retaining states.

iii) Epilepsy: In conjunction with other anticonvulsants best results with DIAMOX Tablets have been seen in petit mal in children. Good results, however, have been seen in patients, both children and adults, with other types of seizures such as grand mal, mixed seizure patterns, myoclonic jerk patterns etc.

4.2 Posology and method of administration

i) Glaucoma (simple acute congestive and secondary):

Adults: 250 - 1,000mg (1-4 tablets) per 24 hours, usually in divided doses for amounts over 250mg daily.

ii) Abnormal retention of fluid: Congestive heart failure, drug-induced oedema.

Adults: For diuresis, the starting dose is usually 250 - 375mg (1-1½ tablets) once daily in the morning. If, after an initial response, the patient fails to continue to lose oedema fluid, do not increase the dose but allow for kidney recovery by omitting a day. Best results are often obtained on a regime of 250 - 375mg (1-1½ tablets) daily for two days, rest a day, and repeat, or merely giving the DIAMOX tablets every other day. The use of DIAMOX tablets does not eliminate the need for other therapy, eg. digitalis, bed rest and salt restriction in congestive heart failure and proper supplementation with elements such as potassium in drug-induced oedema.

For cases of fluid retention associated with pre-menstrual tension, a daily dose (single) of 125 - 375mg is suggested.

iii) Epilepsy:

Adults: 250 - 1,000mg daily in divided doses.

Children: 8-30mg/kg in daily divided doses and not to exceed 750mg/day.

The change from other medication to DIAMOX tablets should be gradual.

Elderly: DIAMOX tablets should only be used with particular caution in elderly patients or those with potential obstruction in the urinary tract or with disorders rendering their electrolyte balance precarious or with liver dysfunction.

4.3 Contraindications

Acetazolamide is contra-indicated in situations in which sodium and/or potassium blood levels are depressed, in cases of marked kidney and liver disease or dysfunction, suprarenal gland failure, and hyperchloremic acidosis. DIAMOX tablets should not be used in patients with hepatic cirrhosis as this may increase the risk of hepatic encephalopathy.

Long-term administration of DIAMOX tablets is contra-indicated in patients with chronic non-congestive angle-closure glaucoma since it may permit organic closure of the angle to occur while the worsening glaucoma is masked by lowered intraocular pressure.

DIAMOX tablets should not be used in patients hypersensitive to sulphonamides.

4.4 Special warnings and precautions for use

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 and the available data do not exclude the possibility of an increased risk for Acetazolamide.

Therefore patients should be monitored for signs of suicidal ideation and behaviours and appropriate treatment should be considered. Patients (and caregivers of patients) should be advised to seek medical advice should signs of suicidal ideation or behaviour emerge.

Increasing the dose does not increase the diuresis and may increase the incidence of drowsiness and/or paraesthesia.

Increasing the dose often results in a decrease in diuresis. Under certain circumstances, however, very large doses have been given in conjunction with other diuretics in order to secure diuresis in complete refractory failure.

When DIAMOX tablets is prescribed for long-term therapy, special precautions are advisable. The patient should be cautioned to report any unusual skin rash. Periodic blood cell counts and electrolyte levels are recommended. Fatalities have occurred, although rarely, due to severe reactions to sulphonamides. A precipitous drop in formed blood cell elements or the appearance of toxic skin manifestations should call for immediate cessation of DIAMOX tablets therapy.

In patients with pulmonary obstruction or emphysema where alveolar ventilation may be impaired, DIAMOX tablets may aggravate acidosis and should be used with caution.

In patients with a past history of renal calculi, benefit should be balanced against the risks of precipitating further calculi.

4.5 Interaction with other medicinal products and other forms of interaction

Acetazolamide is a sulphonamide derivative. Sulphonamides may potentiate the effects of folic acid antagonists. Possible potentiation of the effects of folic acid antagonists, hypoglycaemics and oral anti-coagulants may occur. Concurrent administration of acetazolamide and aspirin may result in severe acidosis and increase central nervous system toxicity. Adjustment of dose may be required when DIAMOX tablets is given with cardiac glycosides or hypertensive agents.

When given concomitantly, acetazolamide modifies the metabolism of phenytoin, leading to increased serum levels of phenytoin. Severe osteomalacia has been noted in a few patients taking acetazolamide in combination with other anticonvulsants. There have been isolated reports of reduced primidone and increased carbamazepine serum levels with concurrent administration of acetazolamide.

Because of possible additive effects, concomitant use with other carbonic anhydrase inhibitors is not advisable.

By increasing the pH of renal tubular urine, acetazolamide reduces the urinary excretion of amphetamine and quinidine and so may enhance the magnitude and the duration of effect of amphetamines and enhance the effect of quinidine.

Ciclosporin: Acetazolamide may elevate ciclosporin levels.

Methenamine: Acetazolamide may prevent the urinary antiseptic effect of methenamine.

Lithium: Acetazolamide increases lithium excretion and the blood lithium levels may be decreased.

Sodium bicarbonate: Acetazolamide and sodium bicarbonate used concurrently increases the risk of renal calculus formation.

4.6 Pregnancy and lactation

Use in pregnancy: Acetazolamide has been reported to be teratogenic and embryotoxic in rats, mice, hamsters and rabbits at oral or parenteral doses in excess of ten times those recommended in human beings. Although there is no evidence of these effects in human beings, there are no adequate and well-controlled studies in pregnant women. Therefore, Acetazolamide tablets should not be used in pregnancy, especially during the first trimester.

Use in lactation: Acetazolamide has been detected in low levels in the milk of lactating women who have taken Acetazolamide tablets . Although it is unlikely that this will lead to any harmful effects in the infant, extreme caution should be exercised when Acetazolamide tablets is administered to lactating women.

4.7 Effects on ability to drive and use machines

Increasing the dose does not increase the diuresis and may increase the incidence of drowsiness and/or paraesthesia. Less commonly, fatigue, dizziness and ataxia have been reported. Disorientation has been observed in a few patients with oedema due to hepatic cirrhosis. Such cases should be under close supervision. Transient myopia has been reported.

These conditions invariably subside upon diminution or discontinuance of the medication.

4.8 Undesirable effects

Adverse reactions during short-term therapy are usually non-serious. Those effects which have been noted include: paraesthesia, particularly a “tingling” feeling in the extremities; some loss of appetite; taste disturbance, polyuria, flushing, thirst, headache, dizziness, fatigue, irritability, depression, reduced libido and occasional instances of drowsiness and confusion. Rarely, photosensitivity has been reported.

During long-term therapy, metabolic acidosis and electrolyte imbalance may occasionally occur. This can usually be corrected by the administration of bicarbonate.

Transient myopia has been reported. This condition invariably subsides upon diminution or withdrawal of the medication.

Gastrointestinal disturbances such as nausea, vomiting and diarrhoea.

Acetazolamide is a sulphonamide derivative and therefore some side-effects similar to those caused by sulphonamides have occasionally been reported. These include fever, agranulocytosis, thrombocytopenia, thrombocytic purpura, leukopenia, and aplastic anaemia, bone marrow depression, pancytopenia, rash (including erythema multiforme, Stevens-Johnson Syndrome, toxic epidermal necrolysis), anaphylaxis, crystalluria, calculus formation, renal and ureteral colic, and renal lesions. Rarely, fulminant hepatic necrosis has been reported.

Other occasional adverse reactions include: urticaria, melaena, haematuria, glycosuria, impaired hearing and tinnitus, abnormal liver function, renal failure and rarely, hepatitis or cholestatic jaundice, flaccid paralysis, and convulsions.

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

4.9 Overdose

No specific antidote. Supportive measures with correction of electrolyte and fluid balance. Force fluids.

5. Pharmacological properties
5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Carbonic anhydrase inhibitors.

ATC Code: S01EC01

Acetazolamide is an inhibitor of carbonic anhydrase. By inhibiting the reaction catalysed by this enzyme in the renal tubules, acetazolamide increases the excretion of bicarbonate and of cations, chiefly sodium and potassium, and so promotes alkaline diuresis.

Continuous administration of acetazolamide is associated with metabolic acidosis and resultant loss of diuretic activity. Therefore, the effectiveness of Acetazolamide tablets in diuresis diminishes with continuous use.

By inhibiting carbonic anhydrase in the eye, acetazolamide decreases intra-ocular pressure and is therefore useful in the treatment of glaucoma.

5.2 Pharmacokinetic properties

Acetazolamide is fairly rapidly absorbed from the gastro-intestinal tract with peak plasma concentrations occurring about 2 hours after administration by mouth. It has been estimated to have a plasma half-life of about 4 hours. It is tightly bound to carbonic anhydrase and accumulates in tissues containing this enzyme, particularly red blood cells and the renal cortex. It is also bound to plasma proteins. It is excreted unchanged in the urine; renal clearance being enhanced in alkaline urine.

5.3 Preclinical safety data

Not applicable

6. Pharmaceutical particulars
6.1 List of excipients

Dicalcium phosphate

Corn starch

Magnesium stearate

Sodium starch glycolate

Povidone

6.2 Incompatibilities

None.

6.3 Shelf life

48 months.

6.4 Special precautions for storage

Do not store above 25°C. Store in the original pack in order to protect from light and moisture.

6.5 Nature and contents of container

Amber glass bottles with metal screw-on caps.

Polypropylene bottles with plastic screw-on caps.

The product is supplied in bottles of 112 tablets.

6.6 Special precautions for disposal and other handling

None.

7. Marketing authorisation holder

Mercury Pharmaceuticals Ltd

Capital House,

85 King William Street,

London EC4N 7BL, UK

8. Marketing authorisation number(s)

PL 12762/0147

9. Date of first authorisation/renewal of the authorisation

12/12/2003

10. Date of revision of the text

15/01/2015