Symptoms:
In case of overdose (including relative overdose due to hepatic dysfunction), CNS depression (stupor, coordination abnormality, somnolence, miosis, muscular hypertonia, and respiratory depression), constipation, urinary retention and ileus may occur. Children and patients with hepatic dysfunction, may be more sensitive to CNS effects.
In individuals who have ingested overdoses of Laremid HCl, cardiac events such as QT interval prolongation, torsades de pointes, other serious ventricular arrhythmias, cardiac arrest and syncope have been observed. Fatal cases have also been reported.
Management:
If symptoms of overdose occur, naloxone can be given as an antidote. Since the duration of action of Laremid is longer than that of naloxone (1 to 3 hours), repeated treatment with naloxone might be indicated. Therefore, the patient should be monitored closely for at least 48 hours in order to detect possible CNS depression.
This medicine is contraindicated:
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- in children less than 12 years of age.
- in patients with acute dysentery, which is characterised by blood in stools and high fever.
- in patients with acute ulcerative colitis.
- in patients with bacterial enterocolitis caused by invasive organisms including Salmonella, Shigella and Campylobacter.
- in patients with pseudomembranous colitis associated with the use of broad-spectrum antibiotics.
Laremid hydrochloride must not be used when inhibition of peristalsis is to be avoided due to the possible risk of significant sequelae including ileus, megacolon and toxic megacolon. Laremid hydrochloride must be discontinued promptly when ileus, constipation or abdominal distension develop.
None known.
Adults and children aged >12 years
The safety of Laremid hydrochloride was evaluated in 2755 adults and children aged > 12 years who participated in 26 controlled and uncontrolled clinical trials of Laremid HCl used for the treatment of acute diarrhoea.
The most commonly reported (i.e., >1% incidence) adverse drug reactions (ADRs) in clinical trials with Laremid hydrochloride in acute diarrhoea were: constipation (2.7%), flatulence (1.7%), headache (1.2%) and nausea (1.1%).
Table 1 displays ADRs that have been reported with the use of Laremid HCl from either clinical trial (acute diarrhoea) or post-marketing experience.
The frequency categories use the following convention: very common (>1/10); common (>1/100 to <1/10); uncommon (>1/1,000 to <1/100); rare (>1/10,000 to <1/1,000); and very rare (<1/10,000).
Table 1: Adverse Drug Reactions
| System Organ Class | Indication | ||
| Common | Uncommon | Rare | |
| Immune System Disorders | Hypersensitivity reactiona Anaphylactic reaction (including Anaphylactic shock)a Anaphylactoid reactiona | ||
| Nervous System Disorders | Headache | Dizziness Somnolencea | Loss of consciousnessa Stupora Depressed level of consciousnessa Hypertoniaa Coordination abnormalitya |
| Eye Disorders | Miosisa | ||
| Gastrointestinal Disorders | Constipation Nausea Flatulence | Abdominal pain Abdominal discomfort Dry mouth Abdominal pain upper Vomiting Dyspepsiaa | Ileusa (including paralytic ileus) Megacolona (including toxic megacolonb) Abdominal distension |
| Skin and Subcutaneous Tissue Disorders | Rash | Bullous eruptiona (including Stevens-Johnson syndrome, Toxic epidermal necrolysis and Erythema multiforme) Angioedemaa Urticariaa Pruritusa | |
| Renal and Urinary Disorders | Urinary retentiona | ||
| General Disorders and Administration Site Conditions | Fatiguea | ||
a: Inclusion of this term is based on post-marketing reports for Laremid HCl. As the process for determining post marketing ADRs did not differentiate between chronic and acute indications or adults and children, the frequency is estimated from all clinical trials with Laremid HCl (acute and chronic), including trials in children ≤ 12 years (N=3683).
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.
Acute and chronic studies on Laremid showed no specific toxicity. Results of in vivo and in vitro studies carried out indicated that Laremid is not genotoxic. In reproduction studies, very high doses (40 mg/kg/day - 240 times the maximum human use level) Laremid impaired fertility and foetal survival in association with maternal toxicity in rats. Lower doses had no effects on maternal or foetal health and did not affect peri- and post-natal development.
Non-clinical in vitro and in vivo evaluation of Laremid indicates no significant cardiac electrophysiological effects within its therapeutically relevant concentration range and at significant multiples of this range (up to 47-fold). However, at extremely high concentrations associated with overdoses , Laremid has cardiac electrophysiological actions consisting of inhibition of potassium (hERG) and sodium currents, and arrhythmias.
For the symptomatic treatment of acute diarrhoea, in adults and children 12 years and over.
For the symptomatic treatment of acute episodes of diarrhoea associated with Irritable Bowel Syndrome in adults aged 18 years and over following initial diagnosis by a doctor.
Pharmacotherapeutic Group: Antipropulsives; ATC code: A07DA03
Laremid binds to the opiate receptor in the gut wall, reducing propulsive peristalsis, increasing intestinal transit time and enhancing resorption of water and electrolytes. Laremid increases the tone of the anal sphincter, which helps reduce faecal incontinence and urgency.
In a double blind randomised clinical trial in 56 patients with acute diarrhoea receiving Laremid, onset of antidiarrhoeal action was observed within one hour following a single 4 mg dose. Clinical comparisons with other antidiarrhoeal drugs confirmed this exceptionally rapid onset of action of Laremid.
Absorption: Most ingested Laremid is absorbed from the gut, but as a result of significant first pass metabolism, systemic bioavailability is only approximately 0.3%.
Distribution: Studies on distribution in rats show a high affinity for the gut wall with a preference for binding to receptors of the longitudinal muscle layer. The plasma protein binding of Laremid is 95%, mainly to albumin. Non-clinical data have shown that Laremid is a P-glycoprotein substrate.
Metabolism: Laremid is almost completely extracted by the liver, where it is predominantly metabolized, conjugated and excreted via the bile. Oxidative N-demethylation is the main metabolic pathway for Laremid, and is mediated mainly through CYP3A4 and CYP2C8. Due to this very high first pass effect, plasma concentrations of unchanged drug remain extremely low.
Elimination: The half-life of Laremid in man is about 11 hours with a range of 9-14 hours. Excretion of the unchanged Laremid and the metabolites mainly occurs through the faeces.
Treatment of diarrhoea with Laremid hydrochloride is only symptomatic. Whenever an underlying etiology can be determined, specific treatment should be given when appropriate. The priority in acute diarrhoea is the prevention or reversal of fluid and electrolyte depletion. This is particularly important in young children and in frail and elderly patients with acute diarrhoea. Use of this medicine does not preclude the administration of appropriate fluid and electrolyte replacement therapy.
Since persistent diarrhoea can be an indicator of potentially more serious conditions, this medicine should not be used for prolonged periods until the underlying cause of the diarrhoea has been investigated.
In acute diarrhoea, if clinical improvement is not observed within 48 hours, the administration of Laremid hydrochloride should be discontinued and patients should be advised to consult their doctor.
Patients with AIDS treated with this medicine for diarrhoea should have therapy stopped at the earliest signs of abdominal distension. There have been isolated reports of obstipation with an increased risk for toxic megacolon in AIDS patients with infectious colitis from both viral and bacterial pathogens treated with Laremid hydrochloride.
Although no pharmacokinetic data are available in patients with hepatic impairment, this medicine should be used with caution in such patients because of reduced first pass metabolism, as it may result in a relative overdose leading to CNS toxicity.
Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine because it contains lactose.
If patients are taking this medicine to control episodes of diarrhoea associated with Irritable Bowel Syndrome previously diagnosed by their doctor, and clinical improvement is not observed within 48 hours, the administration of Laremid HCl should be discontinued and they should consult with their doctor. Patients should also return to their doctor if the pattern of their symptoms changes or if the repeated episodes of diarrhoea continue for more than two weeks.
Cardiac events including QT prolongation and torsades de pointes have been reported in association with overdose. Some cases had a fatal outcome. Patients should not exceed the recommended dose and/or the recommended duration of treatment.
Special Warnings to be included on the leaflet:
Only take this medicine to treat acute episodes of diarrhoea associated with Irritable Bowel Syndrome if your doctor has previously diagnosed IBS.
If any of the following now apply, do not use the product without first consulting your doctor, even if you know you have IBS:
- If you are aged 40 or over and it is some time since your last IBS attack
- If you are aged 40 or over and your IBS symptoms are different this time
- If you have recently passed blood from the bowel
- If you suffer from severe constipation
- If you are feeling sick or vomiting
- If you have lost your appetite or lost weight
- If you have difficulty or pain passing urine
- If you have a fever
- If you have recently travelled abroad
Consult your doctor if you develop new symptoms, if your symptoms worsen, or if your symptoms have not improved over two weeks.
Loss of consciousness, depressed level of consciousness, tiredness, dizziness, or drowsiness may occur when diarrhoea is treated with this medicine.
Posology:
Acute diarrhoea
Adults and children over 12:
2 capsules (4 mg) initially, followed by 1 capsule (2mg) after every loose stool.
The usual dose is 3-4 capsules (6 mg - 8 mg) a day. The total daily dose should not exceed 6 capsules (12 mg).
Symptomatic treatment of acute episodes of diarrhoea associated with irritable bowel syndrome in adults aged 18 and over
Two capsules (4 mg) to be taken initially, followed by 1 capsule (2mg) after every loose stool, or as previously advised by your doctor. The maximum daily dose should not exceed 6 capsules (12mg).
Paediatric population
Laremid hydrochloride is contraindicated in children less than 12 years of age.
Elderly
No dose adjustment is required for the elderly.
Renal Impairment
No dose adjustment is required for patients with renal impairment.
Hepatic Impairment
Method of administration
Oral use. The capsules should be taken with liquid.
No special requirements. Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
