Molipaxin

Overdose

Features of toxicity

The most frequently reported reactions to overdose have included drowsiness, dizziness, nausea and vomiting. In more serious cases coma, tachycardia, hypotension, hyponatraemia, convulsions and respiratory failure have been reported. Cardiac features may include bradycardia, QT prolongation and torsade de pointes. Symptoms may appear 24 hours or more after overdose.

Overdoses of Molipaxin/Trazodone in combination with other antidepressants may cause serotonin syndrome.

Management

There is no specific antidote to trazodone. Activated charcoal should be considered in adults who have ingested more than 1 g trazodone, or in children who have ingested more than 150 mg trazodone within 1 hour of presentation. Alternatively, in adults, gastric lavage may be considered within 1 hour of ingestion of a potentially life-threatening overdose.

Observe for at least 6 hours after ingestion (or 12 hours if a sustained release preparation has been taken). Monitor BP, pulse and Glasgow Coma Scale (GCS). Monitor oxygen saturation if GCS is reduced. Cardiac monitoring is appropriate in symptomatic patients.

Single brief convulsions do not require treatment. Control frequent or prolonged convulsions with intravenous diazepam (0.1-0.3 mg/kg body weight) or lorazepam (4 mg in an adult and 0.05 mg/kg in a child). If these measures do not control the fits, an intravenous infusion of phenytoin may be useful. Give oxygen and correct acid base and metabolic disturbances as required.

Treatment should be symptomatic and supportive in the case of hypotension and excessive sedation. If severe hypotension persists consider use of inotropes, e.g. dopamine or dobutamine

Shelf life

36 months.

Molipaxin price

We have no data on the cost of the drug.
However, we will provide data for each active ingredient

Contraindications

- Known sensitivity to trazodone and any of the excipients.

- Alcohol intoxication and intoxication with hypnotics.

- Acute myocardial infarction.

Incompatibilities

None stated.

List of excipients

Lactose

Magnesium stearate

Gelatin

Titanium dioxide E171

Erythrosine E127

Indigo Carmine E132

Red iron oxide E172

Yellow iron oxide E172

Ink ( black iron oxide E172, shellac, propylene glycol and ammonium hydroxide (pH adjustment) or black iron oxide E172, shellac, propylene glycol, strong ammonia solution (pH adjustment) and potassium hydroxide (pH adjustment))

Pharmaceutical form

Capsules.

Undesirable effects

Cases of suicidal ideation and suicidal behaviours have been reported during Molipaxin/Trazodone therapy or early after treatment discontinuation.

Molipaxin/Trazodone has had no effect on arterial blood pCO2 or pO2 levels in patients with severe respiratory insufficiency due to chronic bronchial or pulmonary disease.

The following symptoms, some of which are commonly reported in cases of untreated depression, have also been recorded in patients receiving Molipaxin/Trazodone therapy.

MedDRA System Organ Class

Frequency not known (cannot be estimated from the available data)

Blood and the lymphatic system disorders

Blood dyscrasias (including agranulocytosis, thrombocytopenia, eosinophilia, leucopenia and anaemia)

Immune system disorders

Allergic reactions

Endocrine disorders

Syndrome of Inappropriate Antidiuretic Hormone Secretion

Metabolism and nutrition disorders

Hyponatraemia1, weight loss, anorexia, increased appetite,

Psychiatric disorders

Suicidal ideation or suicidal behaviours2, confusional state, insomnia, disorientation, mania, anxiety, nervousness, agitation (very occasionally exacerbating to delirium), delusion, aggressive reaction, hallucinations, nightmares, libido decreased, withdrawal syndrome

Nervous system disorders

Serotonin syndrome, convulsion, neuroleptic malignant syndrome, dizziness, vertigo, headache, drowsiness3, restlessness, decreased alertness, tremor, blurred vision, memory disturbance, myoclonus, expressive aphasia, paraesthesia, dystonia, taste altered

Cardiac disorders

Cardiac arrhythmias4 (including Torsade de Pointes, palpitations, premature ventricular contractions, ventricular couplets, ventricular tachycardia), bradycardia, tachycardia, ECG abnormalities (QT prolongation)2

Vascular disorders

Orthostatic hypotension, hypertension, syncope

Respiratory, thoracic and mediastinal disorders

Nasal congestion, dyspnoea

Gastrointestinal disorders

Nausea, vomiting, dry mouth, constipation, diarrhoea, dyspepsia, stomach pain, gastroenteritis, increased salivation, paralytic ileus

Hepato-biliary disorders

Hepatic function abnormalities (including jaundice and hepatocellular damage)5 , cholestasis intrahepatic, severe hepatic disorders such as hepatitis/fulminant hepatitis and hepatic failure with potentially fatal outcome

Skin and subcutaneous tissue disorders

Skin rash, pruritus, hyperhidrosis

Musculoskeletal and connective tissue disorders

Pain in limb, back pain, myalgia, arthralgia

Renal and urinary disorders

Micturition disorder

Reproductive system and breast disorders

Priapism6

General disorders and administration site conditions

Weakness, oedema, influenza-like symptoms, fatigue, chest pain, fever

Investigations

Elevated liver enzymes

3 Trazodone is a sedative antidepressant and drowsiness, sometimes experienced during the first days of treatment, usually disappears on continued therapy.

4 Studies in animals have shown that trazodone is less cardiotoxic than the tricyclic antidepressants, and clinical studies suggest that the drug may be less likely to cause cardiac arrhythmias in man.

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

None stated.

Therapeutic indications

Anxiety, depression, mixed anxiety and depression.

Pharmacodynamic properties

ATC code: N06A X05. Other antidepressants.

Molipaxin/Trazodone is a potent antidepressant. It also has anxiety reducing activity. Molipaxin/Trazodone is a triazolopyridine derivative chemically unrelated to known tricyclic, tetracyclic and other antidepressant agents. It has negligible effect on noradrenaline re-uptake mechanisms. Whilst the mode of action of Molipaxin/Trazodone is not known precisely, its antidepressant activity may concern noradrenergic potentiation by mechanisms other than uptake blockade. A central antiserotonin effect may account for the drug's anxiety reducing properties.

Pharmacokinetic properties

Trazodone is rapidly absorbed from the gastro-intestinal tract and extensively metabolised. Paths of metabolism of trazodone include n-oxidation and hydroxylation. The metabolic m-chlorophenylpiperazine is active. Trazodone is excreted in the urine almost entirely in the form of its metabolites, either in free or in conjugated form. The elimination of Trazodone is biphasic, with a terminal elimination half-life of 5 to 13 hours. Trazodone is excreted in breast milk.

There was an approximate two-fold increase in terminal phase half-life and significantly higher plasma concentrations of trazodone in 10 subjects aged 65 to 74 years compared with 12 subjects aged 23 to 30 years following a 100mg dose of trazodone. It was suggested that there is an age-related reduction in the hepatic metabolism of trazodone.

In vitro studies in human liver microsomes show that trazodone is metabolised by cytochrome P4503A4 (CYP3A4) to form m-chlorophenylpiperazine. Whilst significant, the role of this pathway in the total clearance of trazodone in vivo has not been fully determined.

Date of revision of the text

29/04/2015

Name of the medicinal product

Molipaxin 100 mg Capsules/Trazodone hydrochloride 100 mg Capsules

Marketing authorisation holder

Winthrop Pharmaceuticals UK Limited

One Onslow Street

Guildford

Surrey

GU1 4YS

UK

Trading as:-

Zentiva, One Onslow Street, Guildford, Surrey, GU1 4YS, UK

Special precautions for storage

Blister packs: Store below 30°C in a dry place.

Glass bottles and securitainers: Store below 30°C.

Nature and contents of container

i) Amber glass bottles with jay-cap closures: contents 100 capsules.

ii) PVdC coated 250μm PVC blisters sealed with 20μm aluminium foil: contents 56 and 100 capsules.

iii) Securitainers: contents 1000 capsules.

Marketing authorisation number(s)

PL 17780/0618

Qualitative and quantitative composition

Trazodone hydrochloride 100mg per capsule.

For excipients see 6.1

Special warnings and precautions for use

Use in children and adolescents under 18

Molipaxin/Trazodone should not be used in children and adolescents under 18 years old. Suicidal behaviour (suicidal attempt and suicidal planning) and hostility (essentially aggressiveness, opposing behavior and anger) has been observed in a clinical study on children and adolescents treated with antidepressant more frequently than with placebo. Moreover, long-term safety data on children and adolescents regarding growth, maturation and cognitive and behavioral development are not available.

Suicide/suicidal thoughts or clinical worsening

Depression is associated with an increased risk of suicidal thoughts, self-harm and suicide (suicide-related events).8 for further information.

Since agranulocytosis may clinically reveal itself with influenza-like symptoms, sore throat, and fever, in these cases it is recommended to check haematology.

Hypotension, including orthostatic hypotension and syncope, has been reported to occur in patients receiving Molipaxin/Trazodone.

As with other drugs with alpha-adrenolytic activity, Molipaxin/Trazodone has very rarely been associated with priapism. This may be treated with an intracavernosum injection of an alpha-adrenergic agent such as adrenaline or metaraminol. However there are reports of Molipaxin/Trazodone -induced priapism which have required surgical intervention or led to permanent sexual dysfunction. Patients developing this suspected adverse reaction should cease Molipaxin/Trazodone immediately.

Molipaxin/Trazodone hydrochloride contains lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.

Effects on ability to drive and use machines

Molipaxin/Trazodone has minor or moderate influence on the ability to drive and use machines.As with all other drugs acting on the central nervous system, patients should be cautioned against the risks of driving or operating machinery until they are sure they are not affected by drowsiness, sedation, dizziness, confusional states, or blurred vision.

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Dosage (Posology) and method of administration

Route of administration: Oral.

DEPRESSION:

Adults:

Initially 150mg/day in divided doses after food or as a single dose on retiring.

This may be increased up to 300mg/day in a single or divided doses. The major portion of a divided dose to be taken on retiring. The dose may be further increased to 600mg/day in divided doses in hospitalised patients.

Elderly:

For very elderly or frail patients, the recommended initial starting dose is reduced to 100 mg/day given in divided doses or as a single night-time dose. This may be incrementally increased, under supervision, according to efficacy and tolerance. In general, single doses above 100mg should be avoided in these patients. It is unlikely that 300 mg/day will be exceeded.

Children:

There are insufficient data on safety to recommend the use of Molipaxin/Trazodone in children below the age of 18 years.

DEPRESSION ACCOMPANIED BY ANXIETY:

As for depression.

ANXIETY:

75 mg/day increasing to 300 mg/day as necessary.

A decrease in side-effects (increase of the resorption and decrease of the peak plasma concentration) can be reached by taking Molipaxin/Trazodone after a meal.

Hepatic Impairment:

4 and 4.8. Therefore caution should be exercised when prescribing for patients with hepatic impairment, particularly in cases of severe hepatic impairment. Periodic monitoring of liver function may be considered.

Renal Impairment:

2).

Special precautions for disposal and other handling

Not applicable.

Date of first authorisation/renewal of the authorisation

26 August 2009