1. Name Of The Medicinal Product
Ucerax Syrup 10 mg/5ml.
2. Qualitative And Quantitative Composition
Each ml contains hydroxyzine hydrochloride 2 mg/ml.
For excipients, see 6.1.
3. Pharmaceutical Form
Syrup.
Clear colourless solution.
4. Clinical Particulars
4.1 Therapeutic Indications
Ucerax is indicated to assist in the management of anxiety.
Ucerax is indicated to assist in the management of pruritus associated with acute and chronic urticaria, including cholinergic and physical types, and in atopic and contact dermatosis in adults and children.
4.2 Posology And Method Of Administration
Adults:
Anxiety.
50 mg/day in 3 separate administrations of 12.5-12.5-25mg. In more severe cases, doses up to 300mg/day can be used.
Pruritus.
Starting dose of 25 mg at night, increasing as necessary to 25 mg three or four times daily.
The maximum single dose in adults should not exceed 200mg whereas the maximum daily doses should not exceed 300mg.
Children:
Children aged from 12 months to 6 years: 1mg/kg/day up to 2.5mg/kg/day in divided doses.
Children aged over 6 years: 1mg/kg/day up to 2mg/kg/day in divided doses.
The dosage should be adjusted according to the patient's response to therapy.
In the elderly, it is advised to start with half the recommended dose due to the prolonged action.
In patients with hepatic dysfunction, it is recommended to reduce the daily dose by 33%.
Dosage should be reduced in patients with moderate or severe renal impairment due to decreased excretion of its metabolite cetirizine.
4.3 Contraindications
Ucerax is contra-indicated in patients with a history of hypersensitivity to any of its constituents, to cetirizine, to other piperazine derivatives, to aminophylline, or to ethylenediamine.
Ucerax is contra-indicated during pregnancy and lactation.
Ucerax is contra-indicated in patients with porphyria.
Ucerax 2 mg/ml Syrup contains 0.75 g of sucrose per ml. Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take this medicine.
4.4 Special Warnings And Precautions For Use
Ucerax should be administered cautiously in patients with increased potential for convulsions.
Young children are more susceptible to develop adverse events related to the central nervous system (see section 4.8). In children, convulsions have been more frequently reported than in adults.
Because of its potential anticholinergic effects, Ucerax should be used cautiously in patients suffering from glaucoma, bladder outflow obstruction, decreased gastro-intestinal motility, myasthenia gravis, or dementia.
Dosage adjustments may be required if Ucerax is used simultaneously with other central nervous system depressant drugs or with drugs having anticholinergic properties (see section 4.5).
The concomitant use of alcohol and Ucerax should be avoided (see section 4.5).
Caution is needed in patients who have a known predisposing factor to cardiac arrhythmia, or who are concomitantly treated with a potentially arrhythmogenic drug. In patients with pre-existing prolonged QT intervals, use of alternative treatments is to be considered.
In the elderly, it is advised to start with half the recommended dose due to a prolonged action.
At a dose higher than 6.5 ml of the 2 mg/ml Ucerax syrup, the sucrose content should be taken into consideration in patients with diabetes mellitus. Sucrose may be harmful to the teeth.
Ucerax 2 mg/ml syrup contains small amounts (0.1 vol %) of ethanol (alcohol). The concentration of alcohol after the administration of 100 ml syrup (equivalent to 200 mg of hydroxyzine) will be up to 100 mg, equivalent to 2 ml beer or 1 ml wine. This has to be taken into account for patient suffering from alcoholism, in pregnant or lactating women, children, and high-risk groups such as patients with liver disease, or epilepsy.
Ucerax dosage should be reduced in patients with hepatic dysfunction and in patients with moderate or severe renal impairment (see section 4.2).
The treatment should be stopped at least 5 days before allergy testing or methacholine bronchial challenge, to avoid effects on the test results.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
The potentiating action of Ucerax must be considered when the drug is used in conjunction with drugs having central nervous system depressant properties or anticholinergic properties, and dosage should be adapted on an individual basis.
Alcohol also potentiates the effects of Ucerax.
Ucerax antagonizes the effects of betahistine, and of anticholinesterase drugs.
The treatment should be stopped at least 5 days before allergy testing or methacholine bronchial challenge, to avoid effects on the test results.
Simultaneous administration of Ucerax with monoamine oxidase inhibitors should be avoided.
Ucerax counteracts the adrenaline pressor action.
In rats, hydroxyzine antagonised the anticonvulsant action of phenytoin.
Cimetidine 600 mg bid has been shown to increase the serum concentrations of hydroxyzine by 36% and to decrease peak concentrations of the metabolite cetirizine by 20%.
Ucerax is an inhibitor of cytochrome CYP2D6 (Ki: 3.9 µM ; 1.7 µg/ml) and may cause at high doses drug-drug interactions with CYP2D6 substrates.
Ucerax has no inhibitory effect at 100 µM on UDP-glucuronyl transferase isoforms 1A1 and 1A6 in human liver microsomes. It inhibits cytochrome P450 2C9, 2C19 and 3A4 isoforms at concentrations (IC50 : 103 to 140 µM ; 46 to 52 µg/ml) well above peak plasma concentrations. The metabolite cetirizine at 100 µM has no inhibitory effect on human liver cytochrome P450 (1A2, 2A6, 2C9, 2C19, 2D6, 2E1 and 3A4) and UDP-glucuronyl transferase isoforms. Therefore, Ucerax is unlikely to impair the metabolism of drugs which are substrates for these enzymes.
As hydroxyzine is metabolized by alcohol dehydrogenase and CYP3A4/5 an increase in hydroxyzine blood concentrations may be expected when hydroxyzine is co-administered with other drugs known to be potent inhibitors of liver enzymes. However, when only one pathway of metabolism is inhibited , the other pathway may partially compensate.
4.6 Pregnancy And Lactation
Animal studies have shown reproductive toxicity.
Hydroxyzine crosses the placental barrier leading to higher fetal than maternal concentrations.
To date, no relevant epidemiological data are available relating to exposure to Ucerax during pregnancy.
In neonates whose mothers received Ucerax during late pregnancy and/or labour, the following events were observed immediately or only a few hours after birth: hypotonia, movement disorders including extrapyramidal disorders, clonic movements, CNS depression, neonatal hypoxic conditions, or urinary retention. Therefore, Ucerax should not be used during pregnancy.
Ucerax is contra-indicated during lactation. Breast-feeding should be stopped if Ucerax therapy is needed.
4.7 Effects On Ability To Drive And Use Machines
Ucerax may impair the ability to react and to concentrate. Patients should be warned of this possibility and cautioned against driving a car or operating machinery. Concomitant use of Ucerax with alcohol or other sedative drugs should be avoided as it aggravates these effects.
4.8 Undesirable Effects
Undesirable effects are mainly related to CNS depressant or paradoxical CNS stimulation effects, to anticholinergic activity, or to hypersensitivity reactions.
A Clinical trials
The following table list the relevant undesirable effects reported in placebo-controlled clinical trials for hydroxyzine and including 735 subjects exposed to hydroxyzine up to 50 mg daily. The frequency has been estimated using the following definitions: very common (
System Organ Class
|
Adverse event preferred term
|
Frequency
|
Nervous system disorders
|
Somnolence
|
Very common
|
Headache
|
Common
|
|
Dizziness
|
Uncommon
|
|
Insomnia
|
Uncommon
|
|
Disturbance in attention
|
Uncommon
|
|
Gastrointestinal disorders
|
Dry mouth
|
Common
|
Constipation
|
Uncommon
|
|
Nausea
|
Uncommon
|
|
General disorders and administration site conditions
|
Fatigue
|
Common
|
Asthenia
|
Uncommon
|
|
B Post-marketing experience
The following table lists, per body system, the additional undesirable adverse reactions reported during marketed use of the drug. No frequency can be estimated from post-marketing reporting of events.
Immune system disorders :
Hypersensitivity, anaphylactic shock
Psychiatric disorders :
Agitation, confusion, disorientation, hallucination
Nervous system disorders :
Sedation, tremor, convulsions, dyskinesia
Eye disorders :
Accommodation disorder, vision blurred
Cardiac disorders :
Tachycardia
Vascular disorders :
Hypotension
Respiratory, thoracic and mediastinal disorders :
Bronchospasm
Gastrointestinal disorders :
Vomiting
Skin and subcutaneous tissue disorders :
Pruritus, erythematous rash, maculo-papular rash, urticaria, dermatitis, angioneurotic oedema, sweating increased, fixed drug eruption
Renal and urinary disorders :
Urinary retention
General disorders and administration site conditions :
Malaise, pyrexia
Investigations :
Liver function tests abnormal
4.9 Overdose
Symptoms observed after an important overdose are mainly associated with excessive anticholinergic load, CNS depression or CNS paradoxical stimulation. They include nausea, vomiting, tachycardia, pyrexia, somnolence, impaired pupillary reflex, tremor, confusion, or hallucination. This may be followed by depressed level of consciousness, respiratory depression, convulsions, hypotension, or cardiac arrhythmia. Deepening coma and cardiorespiratory collapse may ensue.
Airway, breathing and circulatory status must be closely monitored with continuous ECG recording and an adequate oxygen supply should be available. Cardiac and blood pressure monitoring should be maintained until the patient is free of symptoms for 24 hours. Patients with altered mental status should be checked for simultaneous intake of other drugs or alcohol and should be given oxygen, naloxone, glucose, and thiamine if deemed necessary.
Norepinephrine or metaraminol should be used if vasopressor is needed. Epinephrine should not be used.
Syrup of ipecac should not be administered in symptomatic patients or those who could rapidly become obtunded, comatose or convulsing, as this could lead to aspiration pneumonitis. Gastric lavage with prior endotracheal intubation may be performed if a clinically significant ingestion has occurred. Activated charcoal may be left in the stomach but there are scant data to support its efficacy.
It is doubtful that hemodialysis or hemoperfusion would be of any value.
There is no specific antidote.
Literature data indicate that, in the presence of severe, life-threatening, intractable anticholinergic effects unresponsive to other agents, a therapeutic trial dose of physostigmine may be useful. Physostigmine should not be used just to keep the patient awake. If cyclic antidepressants have been coingested, use of physostigmine may precipitate seizures and intractable cardiac arrest. Also avoid physostigmine in patients with cardiac conduction defects.
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
Hydroxyzine is a psycholeptic and anxiolytic agent (ataractic).
ATC code is N05B B01
The active substance, hydroxyzine dihydrochloride, is a diphnylmethane derivative, chemically unrelated to the phenothiazines, reserpine, meprobamate or benzodiazepines.
Mechanism of action
Hydroxyzine is a first generation antihistamine that crosses extensively the blood/brain barrier and has a high affinity for histaminic receptors into the brain, thereby producing sedative-anxiolytic effects.
Pharmacodynamic effects
Antihistaminic and bronchodilatator activities have been demonstrated experimentally and confirmed clinically. An antiemetic effect, both by the apomorphine test and the veriloid test, has been demonstrated. Pharmacological and clinical studies indicate that hydroxyzine at therapeutic dosage does not increase gastric secretion or acidity and in most cases has mild antisecretory activity. Wheal and flare reduction have been demonstrated in adult healthy volunteers and in children after intradermal injections of histamine or antigens. Hydroxyzine has also revealed its efficacy in relieving pruritus in various forms of urticaria, eczema and dermatitis.
Hydroxyzine was studied in eight patients with primary biliary cirrhosis. All had abnormal liver biochemistry tests, all had biopsies compatible with primary cirrhosis, and seven of eight had positive tests for antimitochodrial antibodies. The patients received a single dose of hydroxyzine (0.7mg/kg – mean does 43.9 ± 6.6 mg).
In these subjects with hepatic dysfunction secondary to primary cirrhosis, total body clearance was approximately 66% that of normal subjects (8.65 ± 7.46 ml/min/kg versus 10 ml/min/kg for normal subjects). The half-life was increased to 37 hours and the serum concentrations of the carboxylic metabolite, cetirizine (500.4 ± 302.0 mg/ml), were higher than in young patients with a normal liver function. As hydroxyzine elimination is impaired in patients with hepatic dysfunction, daily dose or dose frequency should be reduced in patients with impaired liver function.
EEG recordings in healthy volunteers show an anxiolytic-sedative profile. Anxiolytic effect was confirmed in patients by the use of various classical psychometric tests. Polysomnographic recordings in anxious and insomniac patients have evidenced an increase in total sleep time, a reduction of total time of night awakenings and a reduction of sleep latency either after single or repeated daily doses of 50 mg. A reduction of the muscular tension was demonstrated in anxious patients at a daily dose of 3 x 50 mg. No memory deficiency has been observed. No withdrawal signs or symptoms have appeared after 4-week treatment in anxious patients.
Onset of action
The antihistaminic effect begins approximately after 1 hour with oral pharmaceutical forms. The sedative effect starts after 5-10 minutes with oral liquid and after 30-45 minutes with tablets.
Hydroxyzine has a weak affinity for muscarinic receptors.
5.2 Pharmacokinetic Properties
5.2 Pharmacokinetic properties
Absorption
Hydroxyzine is rapidly absorbed from the gastro-intestinal tract. The peak plasma level (Cmax) is reached approximately two hours after oral intake. After single oral doses of 25 mg and 50 mg in adults, Cmax concentrations are typically 30 and 70 ng/ml, respectively. The rate and extent of exposure to hydroxyzine is very similar when given as tablet or as a syrup. Following repeat administration once a day, concentrations are increased by 30%. The oral bioavailability of hydroxyzine with respect to intramuscular (IM) administration is about 80%. After a single 50 mg IM dose, Cmax concentrations are typically 65 ng/ml.
Distribution
Hydroxyzine is widely distributed in the body and generally more concentrated in the tissues than in plasma. The apparent volume of distribution is 7 to 16 l/kg in adults. Hydroxyzine enters the skin following oral administration. Skin concentrations of hydroxyzine are higher than serum concentrations, following both single and multiple administration. Hydroxyzine crosses the blood-brain and placental barriers leading to higher fetal than maternal concentrations.
Biotransformation
Hydroxyzine is extensively metabolized. The formation of the major metabolite cetirizine, a carboxylic acid metabolite (approximately 45% of the oral dose), is mediated by alcohol dehydrogenase. This metabolite has significant peripheral H1-antagonist properties. An elimination half-life for cetirizine of about 20 hours has been reported. The other metabolites identified include a N-dealkylated metabolite, and an O-dealkylated metabolite with a plasma half-life of 59 hours. These pathways are mediated principally by CYP3A4/5.
Elimination
Across studies, the half life (t½) of hydroxyzine in adults is 12 ± 5 hrs (range 7 – 20 hrs). Across studies the apparent plasma clearance (CL/F) of hydroxyzine is 14 ± 4 ml/min/kg (range 9.4-17.5 ml/min/kg).
The apparent total body clearance calculated across studies is 13 ml/min/kg. Only 0.8% of the dose is excreted unchanged in urine. The major metabolite cetirizine is excreted mainly unchanged in urine (25% and 16 % of the hydroxyzine oral and IM dose, respectively).
After a single dose of 50 mg hydroxyzine, the Cmax of cetirizine (261 ng/ml) was comparable to that after a single dose of 10 mg cetirizine (282 ng/ml) but the AUC was similar to that after a single dose of 20 mg cetirizine.
Special population
Elderly patients
The pharmacokinetics of hydroxyzine was investigated in 9 healthy elderly subjects (69.5 ± 3.7 years) following a single 0.7 mg/kg oral dose. The elimination half-life of hydroxyzine was prolonged to 29± 10 hrs (range 20-53 hrs) and the apparent volume of distribution was increased to 22 ± 6 l/kg (range 13 -31 l/kg). In view of the longer t½ and of the prolonged Pharmacodynamic effect (suppression of the wheal and flare response to histamine), it is advised to start with half the recommended dose (see section 4.2).
Paediatric patients
The pharmacokinetics of hydroxyzine was evaluated in 12 paediatric patients aged 1 to 14 years (mean 6.1 ± 4.6 yrs) with severe atopic dermatitis. A 0.7 mg/kg single dose of hydroxyzine was administered orally. The mean peak serum concentration was 47 ± 17 ng/ml and occurred at a mean time of 2.0 ± 0.9h after the dose. The mean plasma clearance was higher than in adults (32 ± 11 ml/min/kg). The half-life was shorter than in adults and increased with age from 4 hrs at 1 year of age to 11 hrs at 14 years of age. No data was available regarding the metabolite cetirizine.
Like in adults, the antipruritic effect lasted longer than anticipated for the half-life as pruritus was significantly suppressed from 1 to 24 hrs post-dose with>85% suppression from 2 to 12 hrs.
Dosage should be adjusted in paediatric population (see section 4.2).
Hepatic impairment
Hydroxyzine was studied in eight patients with primary biliary cirrhosis. All had abnormal liver biochemistry tests, all had biopsies compatible with primary cirrhosis, and seven of eight had positive tests for antimitochodrial antibodies. The patients received a single dose of hydroxyzine (0.7mg/kg – mean does 43.9 ± 6.6 mg).
In these subjects with hepatic dysfunction secondary to primary cirrhosis, total body clearance was approximately 66% that of normal subjects (8.65 ± 7.46 ml/min/kg versus 10 ml/min/kg for normal subjects). The half-life was increased to 37 hours and the serum concentrations of the carboxylic metabolite, cetirizine (500.4 ± 302.0 mg/ml), were higher than in young patients with a normal liver function. As hydroxyzine elimination is impaired in patients with hepatic dysfunction, daily dose or dose frequency should be reduced in patients with impaired liver function (see section 4.2).
Renal impairment
The pharmacokinetics of hydroxyzine was studied in 8 severe renally impaired subjects (Creatinine clearance: 24 ± 7 ml/min). The extent of exposure (AUC) to hydroxyzine was not altered in a relevant manner while that to the carboxylic metabolite, cetirizine, was increased. This metabolite is not removed efficiently by hemodialysis. In order to avoid any important accumulation of the cetirizine metabolite following multiple doses of hydroxyzine, the daily dose of hydroxyzine should be reduced in subjects with impaired renal function (see section 4.2).
5.3 Preclinical Safety Data
There is no pre-clinical data of relevance to the subscriber additional to that noted in other sections of this SPC.
6. Pharmaceutical Particulars
6.1 List Of Excipients
Ethanol
Sucrose
Sodium benzoate
Levomenthol
Imitation hazelnut flavour (containing a.o. propylene glycol, vanillin, ethyl vanillin, fenugreek, seed extract, lovage oil)
Purified water
6.2 Incompatibilities
None.
6.3 Shelf Life
3 years
6.4 Special Precautions For Storage
Store in the original package.
6.5 Nature And Contents Of Container
Amber glass bottle, with a polypropylene screw cap and polyethylene inner liner, containing 100 or 200 ml of syrup
6.6 Special Precautions For Disposal And Other Handling
Not applicable.
7. Marketing Authorisation Holder
UCB Pharma Limited
208 Bath Road
Slough
Berkshire
SL1 3WE
8. Marketing Authorisation Number(S)
PL 00039/0537
9. Date Of First Authorisation/Renewal Of The Authorisation
16 August 2001
10. Date Of Revision Of The Text
August 2010
