Overdose
Symptoms
The most important signs to be expected following acute overdose are CNS symptoms such as confusion, dizziness, impairment of consciousness and convulsive seizures increases in QT interval as well as gastrointestinal reactions such as nausea and mucosal erosions.
CNS effects including confusional state, convulsion, hallucination, and tremor have been observed in post marketing experience.
Management
In the case of overdose steps to remove any unabsorbed Floxal e.g. gastric lavage, administration of adsorbants and sodium sulphate, if possible during the first 30 minutes, are recommended; antacids are recommended for protection of the gastric mucosa.
In the event of overdose, symptomatic treatment should be implemented. ECG monitoring should be undertaken, because of the possibility of QT interval prolongation. Antacids may be used for protection of gastric mucosa. A fraction of Floxal may be removed from the body with haemodialysis. Peritoneal dialysis and CAPD are not effective in removing Floxal from the body. No specific antidote exists.
Elimination of Floxal may be increased by forced diuresis.
Contraindications
The use of Floxal is contraindicated as follows:
-
- In patients with a history of epilepsy or an existing central nervous system disorder with a lowered seizure threshold.
- In patients with a history of tendon disorders related to fluoroquinolone administration
- In children or growing adolescents, and in pregnant or breastfeeding women, since animal experiments do not entirely exclude the risk of damage to the growth-plate cartilage in the growing organism cannot be entirely excluded.
- In patients with latent or actual defects in glucose-6-phosphate dehydrogenase activity because they may be prone to haemolytic reactions when treated with quinolone antibacterial agents.
Incompatibilities
Not applicable
Pharmaceutical form
Eye drops; Eye ointment
Undesirable effects
The information given below is based on data from clinical studies and on extensive post marketing experience.
| System organ class | 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)* |
| Infections and infestations | Fungal infection, Pathogen resistance | | | |
| Blood and lymphatic system disorders | | | Anaemia, Haemolytic anaemia, Leucopenia, Eosinophilia, Thrombocytopenia | Agranulocytosis, Bone marrow failure, Pancytopenia |
| Immune system disorders | | Anaphylactic reaction*, Anaphylactoid reaction*, Angioedema* | Anaphylactic shock*, Anaphylactoid shock* | |
| Metabolism and Nutrition disorders | | Anorexia | | Hypoglycaemia in diabetics treated with hypoglycaemic agents , Hyperglycaemia, Hypoglycaemic coma |
| Psychiatric disorders | Agitation, Sleep disorder, Insomnia | Psychotic disorder (for e.g. hallucination), Anxiety, Confusional state, Nightmares, Depression | | Psychotic disorder and depression with self-endangering behaviour including suicidal ideation or suicide attempt , Nervousness |
| Nervous system disorders | Dizziness, Headache | Somnolence, Paraesthesia, Dysgeusia, Parosmia | Peripheral sensory neuropathy*, Peripheral sensory motor neuropathy* , Convulsion*, Extra-pyramidal symptoms or other disorders of muscular coordination | Tremor, Dykinesia, Ageusia, Syncope |
| Eye disorders | Eye irritation | Visual disturbance | | Uveitis |
| Ear and labyrinth disorders | Vertigo | | Tinnitus, Hearing loss | Hearing impaired |
| Cardiac disorders | | Tachycardia | | Ventricular arrhythmias and torsades de pointes (reported predominantly in patients with risk factors for QT prolongation), ECG QT prolonged |
| Vascular disorders | | Hypotension | | |
| Respiratory, thoracic and mediastinal disorders | Cough, Nasopharyngitis | Dyspnoea, Bronchospasm | | Allergic pneumonitis, Severe dyspnoea |
| Gastrointestinal disorders | Abdominal pain, Diarrhoea, Nausea, Vomiting | Enterocolitis, sometimes haemorrhagic | Pseudomembranous colitis* | Dyspepsia, Flatulence, Constipation, Pancreatitis |
| Hepatobiliary disorders | | Hepatic enzymes increased (ALAT, ASAT, LDH, gamma-GT and/or alkaline phosphatase), Blood bilirubin increased | Jaundice cholestatic | Hepatitis, which may be severe* Severe liver injury, including cases with acute liver failure, sometimes fatal, have been reported with Floxal, primarily in patients with underlying liver disorders. |
| Skin and subcutaneous tissue disorders | Pruritus, Rash | Urticaria, Hot flushes, Hyperhidrosis Pustular rash | Erythema multiforme, Toxic epidermal necrolysis, Photo-sensitivity reaction*, Drug eruption , Vascular purpura, Vasculitis, which can lead in exceptional cases to skin necrosis | Stevens-Johnson syndrome, Acute generalised exanthemous pustulosis, Drug rash, Stomatitis Exfoliative dermatitis |
| Musculoskeletal and connective tissue disorders | | Tendonitis | Arthralgia, Myalgia, Tendon rupture (e.g. Achilles tendon) which may occur within 48 hours of treatment start and may be bilateral | Rhabdomyolysis and/or Myopathy, Muscular weakness, Muscle tear, Muscle rupture, Ligament rupture, Arthritis |
| Renal and urinary disorders | | Serum creatinine increased | Acute renal failure | Acute interstitial nephritis |
| Congenital, familial and genetic disorders | | | | Attacks of porphyria in patients with porphyria |
| General disorders and administration site conditions | | | | Asthenia, Pyrexia, Pain (including pain in back, chest and extremities) |
* postmarketing experience
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.
Preclinical safety data
Preclinical effects in conventional studies of safety pharmacology, acute toxicity, repeated dose toxicity, reproductive studies were observed only at exposures considered sufficiently in excess of the maximum human exposure indicating little relevance to clinical use. Joint toxicity was observed at exposure in the human therapeutic range in juvenile rats and dogs. Floxal exhibits a neurotoxic potential and causes reversible testicular alterations at high doses.
Mutagenicity studies showed no evidence for mutagenicity of Floxal. However, like some other quinolones Floxal is phototoxic in animals at exposure in the human therapeutic range. The phototoxic, photomutagenic and photocarcinogenic potential of Floxal is comparable with that of other gyrase inhibitors.
Preclinical data from conventional genotoxicity studies reveal no special hazard to humans, carcinogen potential has not be investigated.
Reproduction toxicity
Floxal has no effect on fertility, peri- or postnatal development, and therapeutic doses did not lead to any teratogenic or other embryotoxic effects in animals. Floxal crosses the placenta and levels reached in the amniotic fluid are about 30% of the maximal concentrations measured in maternal serum.
Therapeutic indications
The following indications are restricted to adults.
Floxal is suitable for treatment of the following bacterial infections if these are caused by pathogens sensitive to Floxal :
- Lower respiratory tract infections including pneumonia, bronchitits and acute exacerbations of chronic bronchitis caused by gram negative aerobic bacteria. (Floxal tablets are not the drug of first choice in pneumonia caused by Streptococcus pneumoniae, Mycoplasma pneumoniae or Chlamydia pneumoniae);
- Upper and lower urinary tract infections, including uncomplicated (cystitis) and complicated urinary tract infections.
- Uncomplicated urethral and cervical gonorrhoea, non-gonococcal urethritis and cervicitis.
Consideration should be given to official guidance on the appropriate use of anti-bacterial agents.
Pharmacotherapeutic group
Quinolone Antibacterials, Fluoroquinolones
Pharmacodynamic properties
Pharmacotherapeutic group: Quinolone Antibacterials, Fluoroquinolones
ATC code: J01 MA 01
Mechanism of action
Floxal inhibits bacterial DNA replication by inhibiting bacterial topoisomerases, particularly DNA gyrase and topoisomerase IV. It is active after oral administration.
Therapeutic doses of Floxal are devoid of pharmacological effects on the voluntary or autonomic nervous system.
The NCCLS MIC breakpoint recommendations are as follows:
S ≤ 2 mg/l and R > 1 mg/l
Haemophilus influenzae and Neisseria gonorrhoea are exceptions with breakpoints at S ≤ 0.25 mg/l and R > 1 mg/l
The BSAC general recommendations are S ≤ 2 mg/l and R > 4 mg/l
According to DIN 58 940, the following limits apply for Floxal:
S ≤ 1 mg/L, I = 2 mg/L, R > 4 mg/L.
The prevalence of resistance may vary geographically and with time for selected species and local information on resistance is desirable, particularly when treating severe infections. This information gives only an approximate guidance on probabilities whether micro-organisms will be susceptible to Floxal or not.
Only those pathogens relevant to the indications are listed.
| | European range of acquired bacterial resistance to Floxal |
| Normally susceptible | |
| Aerobic Gram-positive micro organisms | |
| S. aureus - methicillin-sensitive | 0.3-12.6% |
| S. pyogenes | 2-5% |
| Aerobic Gram-negative micro organisms | |
| Acinetobacter spp | 0.3-7.3% |
| Citrobacter spp. | 3-15% |
| Enterobacter spp. | 2-13% |
| E. coli | 1-8% |
| H. influenzae | 1% |
| Klebsiella spp. | 1-10% |
| Moraxella spp. | 0-0.2% |
| Morganella morganii | 0-6.9% |
| N. gonorrhoeae | 25% |
| Proteus spp. | 1-15% |
| Serratia marcescens | 2-2.4% |
| Others | |
| Chlamydia spp | |
| L. pneumophila | |
| Intermediately susceptible | |
| Aerobic Gram-positive micro organisms | |
| S. pneumoniae | 70% |
| Providentia | 17.1% |
| Aerobic Gram-negative micro organisms | |
| E. faecalis | 50% |
| P. aeruginosa | 20-30% |
| Serratia spp. | 20-40% |
| Stenotrophomonas maltophilia | 5.1-11% |
| Others | |
| Mycoplasma spp. | 0-5.3% |
| Ureaplasma spp. | 0-2.1% |
| | |
| Resistant | |
| Anaerobic bacteria | |
| S. aureus - methicillin-resistant | 69.2-85.7% |
| T. pallidum | |
Resistance
The main mechanism of bacterial resistance to Floxal involves one or more mutations in the target enzymes, which generally confer resistance to other active substances in the class. Efflux pump and impermeability mechanisms of resistance have also been described and may confer variable resistance to active substances in other classes.
Pharmacokinetic properties
Absorption
The administration of oral doses to fasting volunteers was followed by a rapid and almost complete absorption of Floxal. The peak plasma concentration after a single oral dose of 200mg averaged 2.6 µg/ml and was reached within one hour. The plasma elimination half-life was 5.7 to 7.0 hours and was not dose related.
Distribution
The apparent distribution volume was 120 litres. The plasma concentration did not materially rise with repeat doses (accumulation factor for twice daily dosage: 1.5). The plasma protein binding was approx. 25%.
Biotransformation
The biotransformation of Floxal was below 5%. The two main metabolites found in the urine were N-desmethyl-Floxal and Floxal-N-oxide.
Elimination
Excretion is primarily renal. Between 80 and 90% of the dose were recovered from the urine as unchanged substance.
Floxal was present in the bile in glucuronidised form. The pharmacokinetics of Floxal after intravenous infusion are very similar to those after oral doses. The plasma half-life is prolonged in persons with renal insufficiency; total and renal clearance decrease in accordance with the creatinine clearance. In renal insufficiency the dose should be reduced.
No clinically relevant interactions were seen with food and no interaction was found between Floxal and theophylline.
Special warnings and precautions for use
Floxal tablets are not the drug of first choice in pneumonia caused by Streptococcus pneumoniae or Chlamydia pneumoniae.
Methicillin-resistant S. aureus
Are very likely to possess co-resistance to fluoroquinolones, including Floxal. Therefore Floxal is not recommended for the treatment of known or suspected MRSA infections unless laboratory results have confirmed susceptibility of the organism to Floxal (and commonly recommended antibacterial agents for the treatment of MRSA-infections are considered inappropriate).
Resistance to fluoroquinolones of E. coli
The most common pathogen involved in urinary tract infections - varies across the European Union. Prescribers are advised to take into account the local prevalence of resistance in E. coli to fluoroquinolones.
Severe bullous reactions
Cases of severe bullous skin reactions such as Stevens-Johnson syndrome or toxic epidermal necrolysis have been reported with Floxal. Patients should be advised to contact their doctor immediately prior to continuing treatment if skin and/or mucosal reactions occur.
Tendonitis
Tendonitis, rarely observed with quinolones, may occasionally lead to rupture involving Achilles tendon in particular. Tendinitis and tendon rupture, sometimes bilateral, may occur within 48 hours of starting treatment with Floxal and have been reported up to several months after discontinuation of Floxal. The risk of tendinitis and tendon rupture is increased in patients aged over 60 years and in patients using corticosteroids. The daily dose should be adjusted in elderly patients based on creatinine clearance. Close monitoring of these patients is therefore necessary if they are prescribed Floxal. All patients should consult their physician if they experience symptoms of tendinitis. If tendinitis is suspected, treatment with Floxal must be halted immediately, and appropriate treatment (e.g. immobilisation) must be initiated for the affected tendon.
Hypersensitivity
Hypersensitivity and allergic reactions have been reported for fluoroquinolones after first administration. Anaphylactic and anaphylactoid reactions can progress to life-threatening shock, even after the first administration. In these cases Floxal should be discontinued and suitable treatment (e.g. treatment for shock) should be initiated.
Diseases caused by Clostridium difficile
Diarrhoea, especially if severe, persistent and/or bloody, occurring during or after treatment with Floxal (including several weeks after treatment), may indicate a condition caused by Clostridium difficile, the most severe form of which is pseudomembranous colitis (CDAD) CDAD may range in severity from mild to life threatening, the most severe form of which is pseudomembranous colitis. It is therefore important to consider this diagnosis in patients who develop serious diarrhoea during or after treatment with Floxal. If pseudo-membraneous colitis is suspected, treatment should be discontinued immediately.
Appropriate specific antibiotic therapy must be started without delay (e.g. oral vancomycin, oral teicoplanin or metronidazole). Medicinal products that inhibit peristalsis are contraindicated in such cases.
Patients predisposed to seizures
Quinolones may lower the seizure threshold and may trigger seizures. Floxal is contraindicated in patients with a history epilepsy or with a known predisposition to seizures.
Patients with a known predisposition to seizures may include those with pre-existing central nervous system lesions, concomitant treatment with fenbufen and similar non-steroidal anti-inflammatory drugs (NSAIDs), or with drugs which lower the cerebral seizure threshold, such as theophylline.
In case of convulsive seizures, treatment with Floxal should be discontinued.
Patients with impaired renal function
Since Floxal is eliminated primarily via the kidneys, the dose should be adjusted in patients with impaired renal function.
Patients with history of psychotic disorder
Psychotic reactions have been reported in patients receiving fluoroquinolones including Floxal. In some cases these have progressed to suicidal thoughts or self-endangering behavior including suicide attempt, sometimes after a single dose of Floxal. In the event that a patient develops these reactions, Floxal should be discontinued and appropriate measures instituted.
Floxal should be used with caution in patients with a history of psychotic disorder or in patients with psychiatric disease.
Patients with impaired liver function
Floxal should be used with caution in patients with impaired liver function, as liver damage may occur. Cases of fulminant hepatitis potentially leading to liver failure (including fatal cases) have been reported with fluoroquinolones. Patients should be advised to stop treatment and contact their doctor if signs and symptoms of hepatic disease develop such as anorexia, jaundice, dark urine, pruritus or tender abdomen.
Patients treated with vitamin K antagonists
Due to possible increase in coagulation tests (PT/INR) and/or bleeding in patients treated with fluoroquinolones, including Floxal, in combination with a vitamin K antagonist (e.g. warfarin), coagulation tests should be monitored when these drugs are given concomitantly.
Myasthenia gravis
Fluoroquinolones, including Floxal, have neuromuscular blocking activity and may exacerbate muscle weakness in patients with myasthenia gravis. Postmarketing serious adverse reactions, including deaths and the requirement for respiratory support, have been associated with fluoroquinolone use in patients with myasthenia gravis. Floxal is not recommended in patients with a known history of myasthenia gravis.
Superinfection
As with other antibiotics, the use of Floxal, especially if prolonged, may result in overgrowth of non-susceptible organisms, especially Enteracci, resistant strains of some organisms or Candida. Repeated evaluation of the patient's condition is essential and periodic in vitro susceptibility tests may be useful. If secondary infection occurs during therapy, appropriate measures should be taken.
Prevention of photosensitisation
Photosensitisation has been reported with Floxal. It is recommended that patients should not expose themselves unnecessarily to strong sunlight or to artificial UV rays (e.g. sunray lamp, solarium), during treatment and for 48 hours following treatment discontinuation in order to prevent photosensitisation.
QT interval prolongation
Very rare cases of QT interval proplongation have been reported in patients taking fluoroquinolones.
Caution should be taken when using fluoroquinolones, including Floxal, in patients with known risk factors for prolongation of the QT interval such as, for example:
- elderly patients and women may be more sensitive to QTc-prolonging medications. Therefore, caution should be taken when using fluoroquinolones, including Floxal, in these populations.
- uncorrected electrolyte imbalance (e.g. hypokalemia, hypomagnesemia) - congenital long QT syndrome
- concomitant use of drugs that are known to prolong the QT interval (e.g. Class IA and III anti-arrhythmics, tricyclic antidepressants, macrolides, antipsychotics)
- - cardiac disease (e.g. heart failure, myocardial infarction, bradycardia)
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Dysglycaemia
As with all quinolones, disturbances in blood glucose, including both hypoglycaemia and hyperglycaemia have been reported, usually in diabetic patients receiving concomitant treatment with an oral hypoglycaemic agent (e.g., glibenclamide) or with insulin. Cases of hypoglycaemic coma have been reported. In these diabetic patients, careful monitoring of blood glucose is recommended.
Peripheral neuropathy
Sensory or sensorimotor peripheral neuropathy has been reported in patients receiving fluoroquinolones, including Floxal, which can be rapid in its onset. Floxal should be discontinued if the patient experiences symptoms of neuropathy. This would minimise the possible risk of developing an irreversible condition.
Patients with glucose-6-phosphate-dehydrogenase deficiency
Patients with latent or diagnosed glucose-6-phosphate-dehydrogenase deficiency may be predisposed to haemolytic reactions if they are treated with quinolones. Therefore if Floxal has to be used in these patients, potential occurrence of haemolysis should be monitored.
Interference with laboratory tests
In patients treated with Floxal, determination of opiates or porphyrin levels in urine may give false-positive results. It may be necessary to confirm positive opiate or porphyrin screens by more specific methods.
Vision disorders
If vision becomes impaired or any effects on the eyes are experienced, an eye specialist should be consulted immediately.
Excipient with known effect
Floxal contains lactose anhydrous. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency, or glucose-galactose malabsorption should not take this medicine.
For treatment of severe and/or life-threatening infections parenteral therapy is indicated.
Effects on ability to drive and use machines
Since there have been occasional reports of drowsiness/somnolence, impairment of skills, dizziness/vertigo and visual disturbances, which may impair the patient's ability to concentrate and react, and therefore may constitute a risk in situations where these abilities are of special importance (e.g. driving a car or operating machinery), patients should know how they react to Floxal before they drive or operate machinery. These effects may be enhanced by alcohol.
Dosage (Posology) and method of administration
Posology
The dose of Floxal is determined by the type and severity of the infection. The dosage range for adults is 200 mg to 800 mg daily.
Up to 400 mg may be given as a single dose, preferably in the morning. Generally, individual doses should be given at approximately equal intervals.
In individual cases it may be necessary to increase the dose to a maximum total dose of 800 mg daily, which should be given as 400 mg twice daily, at approximately equal intervals. This may be appropriate in infections due to pathogens known to have reduced or variable susceptibility to Floxal, in severe and/or complicated infections (e.g. of the respiratory or urinary tracts) or if the patient does not respond adequately.
The following doses are recommended:
| Indications | Single and Daily Doses |
| Uncomplicated urethral/ cervical gonorrhoea | 400 mg |
| Uncomplicated lower urinary tract infections | 200 mg-400 mg daily |
| Complicated infections of the upper urinary tract | 400 mg daily, increasing if necessary, to 400 mg twice a day |
| Lower respiratory tract infections | 400 mg daily, increasing, if necessary, to 400 mg twice a day |
| Non-gonococcal urethritis and cervicitis | 400 mg daily |
A single dose of 400 mg of Floxal is sufficient for the treatment of uncomplicated gonorrhoea.
Special patient populations
Impaired renal function
Following a normal initial dose, dosage should be reduced in patients with impairment of renal function as determined by creatinine clearance or plasma creatinine level.
| Creatinine Clearance | Plasma Creatinine | Maintenance Dose* |
| 20 to 50 ml/min* | 1.5 to 5 mg/dl | 100 mg - 200 mg Floxal per day) |
| <20ml/min** | >5 mg/dl | 100 mg Floxal per day |
* According to indication or dose interval
** The serum concentration of Floxal should be monitored in patients with severe renal impairment and dialysis patients.
Patients undergoing haemodialysis or peritoneal dialysis should be given 100 mg Floxal per day.
When creatinine clearance cannot be measured, it can be estimated with reference to the serum creatinine level using the following Cockcroft's formula for adults:
Impaired liver function
The excretion of Floxal may be reduced in patients with severe hepatic dysfunction.
(e.g. cirrhosis of the liver with ascites). In such cases, it is recommended that the dose should not exceed 400 mg Floxal daily, because of possible reduction of excretion.
Paediatric population
Floxal is contraindicated for use in children or growing adolescents.
Elderly
Duration
Treatment should not exceed 2 months duration.
A daily dose of up to 400 mg Floxal may be given as a single dose. In this case, it is preferable to administer Floxal in the morning.
Daily doses of more than 400 mg must be divided into two separate doses and be given at approximately equal intervals.
Method of administration
For oral use.
Floxal tablets should be swallowed whole with sufficient liquid before or during meal times. They should not be taken within two hours of mineral antacids, sucralfate or metal ion preparations (aluminium, iron, magnesium or zinc), didanosine chewable or buffered tablets (for HIV), since reduction of absorption of Floxal can occur.
Special precautions for disposal and other handling
No special requirements.
