- oxycodone hydrochloride
POM: Prescription only medicine
This information is intended for use by health professionals
PosologyThe dosage depends on the intensity of pain and the patient's individual susceptibility to the treatment. For doses not realisable/practicable with this medicinal product other strengths are available.The following general dosage recommendations apply:
Adults and adolescents (12 years of age and older)
Dose titration and adjustmentIn general, the initial dose for opioid naïve patients is 10 mg oxycodone hydrochloride given at intervals of 12 hours. Some patients may benefit from a starting dose of 5 mg to minimize the incidence of adverse reactions.Patients already receiving opioids may start treatment with higher dosages taking into account their experience with former opioid therapies.10-13 mg oxycodone hydrochloride correspond to approximately 20 mg morphine sulphate, both in the prolonged-release formulation.Because of individual differences in sensitivity for different opioids, it is recommended that patients should start conservatively with Carexil® 40 mg Prolonged-release Tablets after conversion from other opioids, with 50-75% of the calculated oxycodone dose.Some patients who take Carexil® 40 mg Prolonged-release Tablets following a fixed schedule need rapid release analgesics as rescue medication in order to control breakthrough pain. Various options for the treatment of breakthrough pain exist with regard to the choice of the active substance, the route of administration and the dosage form. Carexil® 40 mg Prolonged-release Tablets are not indicated for the treatment of acute pain and/or breakthrough pain. The single dose of the rescue medication should amount to 1/6 of the equianalgesic daily dose of Carexil® 40 mg Prolonged-release Tablets. Use of the rescue medication more than twice daily indicates that the dose of Oxycodone Hydrochloride prolonged-release tablets needs to be increased. The dose should not be adjusted more often than once every 1-2 days until a stable twice daily administration has been achieved. Following a dose increase from 10 mg to 20 mg taken every 12 hours dose adjustments should be made in steps of approximately one third of the daily dose. The aim is a patient specific dosage which, with twice daily administration, allows for adequate analgesia with tolerable undesirable effects and as little rescue medication as possible as long as pain therapy is needed.Even administration (the same dose in the morning and in the evening) following a fixed schedule (every 12 hours) is appropriate for the majority of the patients. For some patients it may be beneficial to arrange the doses unevenly. In general, the lowest effective analgesic dose should be chosen. Patients with cancer-related pain may require dosages of 80 to 120 mg, which in individual cases can be increased to up to 400 mg. If even higher doses are required, the dose should be decided individually balancing efficacy against tolerance and the risk of undesirable effects.For the treatment of non malignant pain a daily dose of 40 mg is generally sufficient; but higher dosages may be necessary.
Duration of administrationCarexil® 40 mg Prolonged-release Tablets should not be taken longer than necessary. If long-term treatment is necessary due to the type and severity of the illness careful and regular monitoring is required to determine whether and to what extent treatment should be continued.
Discontinuation of treatmentWhen a patient no longer requires therapy with oxycodone, it may be advisable to taper the dose gradually to prevent symptoms of withdrawal
Older peopleThe lowest dose should be administered with careful titration to pain control.
Patients with renal or hepatic impairmentThe dose initiation should follow a conservative approach in these patients. The recommended adult starting dose should be reduced by 50% (for example a total daily dose of 10 mg orally in opioid naïve patients), and each patient should be titrated to adequate pain control according to their clinical situation.
Special populationsRisk patients, for example patients with low body weight or slow metabolism of medicinal products, should initially receive half the recommended adult dose if they are opioid naïve. Therefore the lowest recommended dosage, i.e. 10 mg, may not be suitable as a starting dose. Dose titration should be performed in accordance with the individual clinical situation.
Children under 12 years of ageCarexil® 40 mg Prolonged-release Tablets are not recommended for children under 12 years of age.
Method of administrationFor oral use.Carexil® 40 mg Prolonged-release Tablets should be taken twice daily based on a fixed schedule at the dosage determined.The prolonged-release tablets may be taken with or independent of meals with a sufficient amount of liquid. Carexil® 40 mg Prolonged-release Tablets must be swallowed whole, and they must not be chewed, divided or crushed.
Caution should be exercised in• elderly or debilitated patients,• patients with severe impairment of lung, liver or kidney function, • Addison's disease, • intoxication psychosis (e.g. alcohol), • prostatic hypertrophy,• adrenocortical insufficiency • alcoholism, known opioid dependence, • delirium tremens, • pancreatitis, • diseases of the biliary tract, biliary or ureteric colic, • inflammatory bowel disorders• conditions with increased brain pressure, • disturbances of circulatory regulation (e.g. hypotensions, hypovolaemia), • epilepsy or seizure tendency, • in patients taking MAO inhibitors or within 2 weeks of discontinuation of their use• and in patients taking naltrexone (see also section 4.5).
Respiratory depressionRespiratory depression is the most significant risk induced by opioids. The respiratory depressant effect of oxycodone can lead to increased carbon dioxide concentrations in blood and hence in cerebrospinal fluid.Myxoedema, HypothyroidismAs with all narcotics, a reduction in dosage may be advisable in patients with hypothyroidism.
Mixed opioid agonists/antagonistsCare should be taken when combining Carexil® 40 mg Prolonged-release Tablets with mixed mu-opioid agonist/antagonists (like pentazocine, nalbuphine) or partial mu-opioid agonists (like buprenorphine). In patients maintained on buprenorphine for the treatment of opioid dependence, alternative treatment options (like e.g. temporary buprenorphine discontinuation) should be considered, if administration of full µ-agonists (like oxycodone) becomes necessary in acute pain situations. On combined use with buprenorphine, higher dose requirements for full µ-receptor agonists have been reported and close monitoring of adverse events such as respiratory depression is required in such circumstances (see also section 4.5).
Tolerance and dependenceLong-term use of Carexil® 40 mg Prolonged-release Tablets can lead to the development of tolerance which leads to the use of higher doses in order to achieve the desired analgesic effect. There is a cross-tolerance to other opioids.Carexil® 40 mg Prolonged-release Tablets have a primary dependence potential. However, when used as intended in patients with chronic pain the risk of developing physical or psychological dependence is markedly reduced. There are no data available on the actual incidence of psychological dependence in chronic pain patients.Chronic use of Carexil® 40 mg Prolonged-release Tablets can cause physical dependence. Withdrawal symptoms may occur following abrupt discontinuation of therapy. If therapy with oxycodone is no longer required it may be advisable to reduce the daily dose gradually in order to avoid the occurrence of a withdrawal syndrome (see also section 4.8). Withdrawal symptoms may include yawning, mydriasis, lacrimation, rhinorrhoea, tremor, hyperhidrosis, anxiety, agitation, convulsions and insomnia.Hyperalgesia that will not respond to a further dose increase of oxycodone may very rarely occur, particularly in high doses. An oxycodone dose reduction or change to an alternative opioid may be required.
AbuseOxycodone has an abuse profile similar to other strong agonist opioids. Oxycodone may be sought and abused by people with latent or manifest addiction disorders. There is potential for development of psychological dependence [addiction] to opioid analgesics, including oxycodone. Carexil® Prolonged-release Tablets should be used with particular care in patients with a history of alcohol and drug abuse.In case of abusive parenteral injection the tablet excipients may lead to necrosis of the local tissue, granulomas of the lung or other serious, potentially fatal events. The tablets must not be crushed, divided, or chewed as this leads to rapid oxycodone release and absorption of a potentially fatal dose of oxycodone (see section 4.9) due to the damage of the prolonged-release properties.
Surgical proceduresThe use of oxycodone prolonged-release tablets is not recommended prior and during the first 12-24 hours after surgical procedures. If further treatment with oxycodone is indicated, the dose should be adjusted to the new post-operative requirements.As with all opioid preparations, oxycodone products should be used with caution following abdominal surgery as opioids are known to impair intestinal motility and should not be used until the physician is assured of normal bowel function.Patients undergoing additional pain-relieving procedures (e.g. surgery, plexus blockade) should not receive oxycodone for 12 hours prior to the intervention.
ChildrenCarexil® 40 mg Prolonged-release Tablets have not been studied in children and adolescents below 12 years of age. The safety and efficacy of the tablets have not been demonstrated and the use in children and adolescents younger than 12 years of age is therefore not recommended.
Patients with severe hepatic impairmentPatients with severe hepatic impairment should be closely monitored.
Paralytic ileusCarexil® 40 mg Prolonged-release Tablets should not be used where there is a possibility of paralytic ileus occurring. Should paralytic ileus be suspected or occur during use, Carexil® 40 mg Prolonged-release Tablets should be discontinued immediately.
AlcoholConcomitant use of alcohol and Carexil® 40 mg Prolonged-release Tablets may increase the undesirable effects of oxycodone; concomitant use should be avoided.
Anti-Doping WarningAthletes must be aware that this medicine may cause a positive reaction to 'anti-doping' tests.
Use of Carexil® 40 mg Prolonged-release Tablets as a doping agent may become a health hazard.This medicinal product contains lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take Carexil® 40 mg Prolonged-release Tablets.
Concomitant administration of oxycodone with serotonin agents, such as a Selective Serotonin Re-uptake Inhibitor (SSRI) or a Serotonin Norepinephrine Re-uptake Inhibitor (SNRI) may cause serotonin toxicity. The symptoms of serotonin toxicity may include mental-status changes (e.g. agitation, hallucinations, coma), autonomic instability (e.g. tachycardia, labile blood pressure, hyperthermia), neuromuscular abnormalities (e.g. hyperreflexia, incoordination, rigidity), and/or gastrointestinal symptoms (e.g. nausea, vomiting, diarrhoea). Oxycodone should be used with caution and the dose may need to be reduced in patients using these medicinal products.• Medicinal products inducing respiratory depression such as benzodiazepines, phenobarbital and other opioids (analgesic, antitussive or substitution treatments) can enhance the risk of respiratory arrest, notably in case of overdose and/or in the elderly.• Central nervous system depressants (e.g. benzodiazepines,be they anxiolytics or hypnotics, antipsychotics, some antidepressants, H1-antihistamines, other opioids, alcohol ) can enhance the sedative effect of oxycodone and impair vigilance. • Anticholinergics (phenothiazine, antipsychotics, tricyclic antidepressants, most non-recent H1 antihistamines, certain antiparkinson medicines) can enhance the anticholinergic undesirable effects of oxycodone (such as constipation, dry mouth or micturition disorders). • Care should be taken if Carexil® 40 mg Prolonged-release Tablets should be used concomitantly with mixed mu-opioid agonist/antagonists (like pentazocine, nalbuphine) or partial mu-opioid agonists (like buprenorphine). In patients maintained on buprenorphine for the treatment of opioid dependence, alternative treatment options (like e.g. temporary buprenorphine discontinuation) should be considered, if administration of full µ-agonists (like oxycodone) becomes necessary in acute pain situations. On combined use with buprenorphine, higher dose requirements for full µ-receptor agonists have been reported and close monitoring of adverse events such as respiratory depression is required in such circumstances (see also section 4.4).• The concomitant use of oxycodone and naltrexone may result in the need for increased oxycodone doses.• Clinically relevant changes in International Normalized Ratio (INR) in both directions have been observed in individuals if coumarin anticoagulants are co-applied with Oxycodone hydrochloride prolonged-release tablets.Oxycodone is metabolised mainly by CYP3A4, with a contribution from CYP2D6. The activities of these metabolic pathways may be inhibited or induced by various co-administered drugs or dietary elements.CYP3A4 inhibitors, such as macrolide antibiotics (e.g. clarithromycin, erythromycin and telithromycin), azol-antifungals (e.g. ketoconazole, voriconazole, itraconazole, and posaconazole), protease inhibitors (e.g. boceprevir, ritonavir, indinavir, nelfinavir and saquinavir), cimetidine and grapefruit juice may cause a reduced clearance of oxycodone that could cause an increase of the plasma concentrations of oxycodone. Therefore the oxycodone dose may need to be adjusted accordingly.Some specific examples are provided below:• Itraconazole, a potent CYP3A4 inhibitor, administered 200 mg orally for five days, increased the AUC of oral oxycodone. On average, the AUC was approximately 2.4 times higher (range 1.5 - 3.4).• Voriconazole, a CYP3A4 inhibitor, administered 200 mg twice-daily for four days (400 mg given as first two doses), increased the AUC of oral oxycodone. On average, the AUC was approximately 3.6 times higher (range 2.7 - 5.6).• Telithromycin, a CYP3A4 inhibitor, administered 800 mg orally for four days, increased the AUC of oral oxycodone. On average, the AUC was approximately 1.8 times higher (range 1.3 2.3).• Grapefruit Juice, a CYP3A4 inhibitor, administered as 200 ml three times a day for five days, increased the AUC of oral oxycodone. On average, the AUC was approximately 1.7 times higher (range 1.1 2.1).CYP3A4 inducers, such as rifampicin, carbamazepin, phenytoin and St John´s Wort may induce the metabolism of oxycodone and cause an increased clearance of oxycodone that could cause a reduction of the plasma concentrations of oxycodone. The oxycodone dose may need to be adjusted accordingly.Some specific examples are provided below:• St Johns Wort, a CYP3A4 inducer, administered as 300 mg three times a day for fifteen days, reduced the AUC of oral oxycodone. On average, the AUC was approximately 50% lower (range 37-57%).• Rifampicin, a CYP3A4 inducer, administered as 600 mg once-daily for seven days, reduced the AUC of oral oxycodone. On average, the AUC was approximately 86% lowerDrugs that inhibit CYP2D6 activity, such as paroxetine and quinidine, may cause decreased clearance of oxycodone which could lead to an increase in oxycodone plasma concentrations.
PregnancyThere are limited data from the use of oxycodone in pregnant women. Infants born to mothers who have received opioids during the last 3 to 4 weeks before giving birth should be monitored for respiratory depression. Withdrawal symptoms may be observed in the newborn of mothers undergoing treatment with oxycodone
BreastfeedingOxycodone may be secreted in breast milk and may cause respiratory depression in the newborn. Oxycodone should, therefore, not be used in breastfeeding mothers.
Immune system disordersUncommon: hypersensitivityNot known: anaphylactic responses.
Blood and lymphatic system disordersRare: lymphadenopathy
Endocrine disordersUncommon: syndrome of inappropriate antidiuretic hormone secretion
Metabolism and nutrition disordersCommon: decreased appetiteUncommon: dehydration
Psychiatric disordersCommon: anxiety, depression, nervousness, insomnia, abnormal thinking, confusional state Uncommon: agitation, affect lability, euphoric mood, hallucinations, decreased libido, drug dependence (see section 4.4), hyperacousisNot known: aggression
Nervous system disordersVery common: somnolence, dizziness, headache Common: tremor, Uncommon: amnesia, convulsion, increased or decreased muscle tone, involuntary muscle contractions, speech disorder, syncope, paraesthesia, dysgeusia, hypaesthesia, coordination disturbances, Rare: muscle spasmNot known: hyperalgesia
Eye disordersUncommon: visual impairment, lacrimation disorder, miosis
Ear and labyrinth disordersUncommon: vertigo
Cardiac disordersUncommon: palpitations (in the context of withdrawal syndrome), supraventricular tachycardia
Vascular disordersUncommon: vasodilatation Rare: hypotension, orthostatic hypotension
Respiratory, thoracic and mediastinal disordersCommon: dyspnoea, brochospasm Uncommon: respiratory depression, increased coughing, pharyngitis, rhinitis, voice changes
Gastrointestinal disordersVery common: constipation, nausea, vomiting Common: dry mouth, gastrointestinal disorders such as abdominal pain, diarrhoea, dyspepsia, loss of appetite Uncommon: dysphagia, eructation, ileus, oral ulcers, gingivitis, stomatitis, flatulence Rare: gingival bleeding, increased appetite, tarry stool, tooth staining and damageNot known: dental cariesHepatobiliary disordersUncommon: increased hepatic enzymesNot known: cholestasis, biliary colic
Skin and subcutaneous tissue disordersVery common: pruritusCommon: rash, hyperhidrosis Uncommon: dry skinRare: manifestations of herpes simplex, increased photosensitivity, urticaria Very rare: exfoliative dermatitis
Renal and urinary disordersCommon: increased urge to urinate Uncommon: urinary retentionRare: haematuria
Reproductive system and breast disordersUncommon: erectile dysfunction Not known: amenorrhoea
General disorders and administration site conditionsCommon: asthenic conditions, Uncommon: chills, accidental injuries, pain (e.g. chest pain), oedema, peripheral oedema, migraine, drug withdrawal syndrome, drug tolerance, thirst Rare: weight changes (increase or decrease), cellulitis Prolonged use of Carexil® 40 mg Prolonged-release Tablets may lead to physical dependence and a withdrawal syndrome may occur upon abrupt cessation of therapy. When a patient no longer requires therapy with oxycodone, it may be advisable to taper the dose gradually to prevent symptoms of withdrawal. The opioid abstinence or withdrawal syndrome is characterised by some or all of the following: restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, mydriasis and palpitations. Other symptoms also may develop, including: irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhoea, or increased blood pressure, respiratory rate or heart rate.
Reporting of suspected adverse reactionsReporting 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 (www.mhra.gov.uk/yellowcard).
SymptomsMiosis, respiratory depression, somnolence, reduced skeletal muscle tone and drop in blood pressure. In severe cases circulatory collapse, stupor, coma, bradycardia and non-cardiogenic lung oedema may occur; abuse of high doses of strong opioids such as oxycodone can be fatal.
TherapyPrimary attention should be given to the establishment of a patent airway and institution of assisted or controlled ventilation.In case of overdose, intravenous administration of an opiate antagonist (e.g. 0.4-2 mg intravenous naloxone) may be indicated. Administration of single doses must be repeated depending on the clinical situation at intervals of 2 to 3 minutes. Intravenous infusion of 2 mg of naloxone in 500 ml isotonic saline or 5% dextrose solution (corresponding to 0.004 mg naloxone/ml) is possible. The rate of infusion should be adjusted to the previous bolus injections and the response of the patient. Naloxone should not be administered in the absence of clinically significant respiratory or circulatory depression secondary to oxycodone overdose. Naloxone should be adminsitered cautiously to patients who are known, or suspected, to be physically dependent on oxycodone. In such cases, an abrupt or complete reversal of opioid effects may precipitate pain and an acute withdrawal syndrome.Gastric lavage can be taken into consideration. The adminsitration of activated charcoal (50 g for adults, 10 -15 g for children) should be considered within 1 hour, if a substantial amount has been ingested within 1 hour, provided the airway can be protected. It may be reasonable to assume that late administration of activated charcoal may be beneficial for prolonged-release preparations; however there is no evidence to support this. For speeding up the passage a suitable laxative (e.g. a PEG-based solution) may be useful. Supportive measures (artificial respiration, oxygen supply, administration of vasopressors and infusion therapy) should, if necessary, be applied in the treatment of accompanying circulatory shock. Upon cardiac arrest or cardiac arrhythmias, cardiac massage or defibrillation may be indicated. If necessary, assisted ventilation as well as maintenance of water and electrolyte balance.
AbsorptionThe relative bioavailability of Carexil® 40 mg Prolonged-release Tablets is comparable to that of rapid-release oxycodone with maximum plasma concentrations being achieved after approximately 3 hours after intake of the prolonged-release tablets compared to 1 to 1.5 hours. Peak plasma concentrations and oscillations of the concentrations of oxycodone from the prolonged-release and rapid-release formulations are comparable when given at the same daily dose at intervals of 12 and 6 hours respectively.The tablets must not be crushed, divided, or chewed as this leads to rapid oxycodone release and absorption of a potentially fatal dose of oxycodone due to the damage of the prolonged-release properties.
DistributionThe absolute bioavailability of oxycodone is approximately two thirds relative to parenteral administration. In steady state, the volume of distribution of oxycodone amounts to 2.6 l/kg; plasma protein binding to 38-45%; the elimination half-life to 4 to 6 hours and plasma clearance to 0.8 l/min. The elimination half-life of oxycodone from prolonged-release tablets is 4-5 hours with steady state values being achieved after a mean of 1 day.
MetabolismOxycodone is metabolised in the intestine and liver via the P450 cytochrome system to noroxycodone and oxymorphone as well as to several glucuronide conjugates. In vitro studies suggest that therapeutic doses of cimetidine probably have no relevant effect on the formation of noroxycodone. In man, quinidine reduces the production of oxymorphone while the pharmacodynamic properties of oxycodone remain largely unaffected. The contribution of the metabolites to the overall pharmacodynamic effect is irrelevant.
EliminationOxycodone and its metabolites are excreted via urine and faeces. Oxycodone crosses the placenta and is found in breast milk.
Linearity/non-linearityAcross the 5-80 mg dose range of prolonged release oxycodone tablets linearity of plasma concentrations was demonstrated in terms of rate and extent of absorption.
Tablet coreHydrogenated castor oilCopovidoneBehenoyl polyoxylglyceridesLactose monohydrate.Magnesium stearateMaize starchColloidal anhydrous silicaTriglycerides, medium-chain
Tablet coatingMicrocrystalline celluloseHypromelloseStearic acidTitanium dioxide (E 171)iron oxide yellow (E 172)
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