Imodium Liquid, 2 mg/15 ml Oral Solution PL 15513/0182
Imodium Liquid, 2 mg/15 ml Oral Solution
PL 15513/0182
UKPAR
TABLE OF CONTENTS
Lay summary
Page 2
Scientific discussion
Page 3
Steps taken for assessment
Page 13
Summary of product characteristics
Page 14
Patient information leaflet
Page 20
Labelling
Page 22
Annex I
Page 25
Annex II
Page 31
UKPAR Imodium Liquid, 2 mg/15 ml Oral Solution
PL 15513/0182
IMODIUM LIQUID, 2 MG/15 ML ORAL SOLUTION
PL 15513/0182
LAY SUMMARY
The Medicines and Healthcare products Regulatory Agency (MHRA) granted a Marketing
Authorisation (licence) for the medicinal product Imodium Liquid, 2 mg/15 ml oral solution
(Product Licence number: 15513/0182).
Imodium Liquid, 2 mg/15 ml oral solution is used to treat sudden, short-lived (acute) attacks
of diarrhoea in adults and children aged 12 years and over. It can also be used to treat
diarrhoea associated with Irritable Bowel Syndrome (IBS) in adults.
Imodium Liquid, 2 mg/15 ml oral solution raised no clinically significant safety concerns and
it was, therefore, judged that the benefits of using this product outweigh the risks; hence a
Marketing Authorisation has been granted.
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UKPAR Imodium Liquid, 2 mg/15 ml Oral Solution
PL 15513/0182
IMODIUM LIQUID, 2 MG/15 ML ORAL SOLUTION
PL 15513/0182
SCIENTIFIC DISCUSSION
TABLE OF CONTENTS
Introduction
Page 4
Pharmaceutical assessment
Page 5
Non-clinical assessment
Page 7
Clinical assessment
Page 8
Overall conclusions and risk benefit assessment
Page 12
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UKPAR Imodium Liquid, 2 mg/15 ml Oral Solution
PL 15513/0182
INTRODUCTION
Based on the review of the data on quality, safety and efficacy, the MHRA granted McNeil
Products Ltd a Marketing Authorisation for the medicinal product Imodium Liquid,
2 mg/15 ml oral solution (PL 15513/0182) on 5 May 2010. This medicine is available without
prescription from pharmacies.
This application for Imodium Liquid, 2 mg/15 ml oral solution is submitted under Article 8.3
of EC Directive 2001/83 as a line extension application. This application cross-refers to
Imodium Capsules (PL 00242/0028), licensed to Jansen-Cilag Limited since 17 March 1975.
Imodium Liquid, 2 mg/ 15 ml oral solution is indicated for the symptomatic treatment of
acute diarrhoea in adults and children aged 12 years and over and 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.
.
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UKPAR Imodium Liquid, 2 mg/15 ml Oral Solution
PL 15513/0182
PHARMACEUTICAL ASSESSMENT
DRUG SUBSTANCE: LOPERAMIDE HYDROCHLORIDE
Chemical Name:
4-(4-chlorophenyl)-4-hydroxy-N,N-dimethyl-α,α-diphenyl-1piperidinebutanamide monohydrochloride
Structure:
Molecular Weight: 513.50
CAS Number: 034552-83-5
Molecular Formula: C29H33ClN2O2.HCl
General Properties
Loperamide hydrochloride is a white or almost white powder that is slightly soluble in water,
freely soluble in alcohol and in methanol.
The method of manufacture of loperamide hydrochloride is appropriate.
The proposed drug substance specification and its justification, analytical procedures and
their validation, batch analyses and reference standards used by the drug substance
manufacturer are satisfactory.
Satisfactory certificates of analysis have been provided for working standards used by the
active substance manufacturer and finished product manufacturer during validation studies.
Loperamide hydrochloride is stored in appropriate packaging. The specifications and typical
analytical test reports are provided and are satisfactory.
Appropriate stability data have been generated supporting the retest period.
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UKPAR Imodium Liquid, 2 mg/15 ml Oral Solution
PL 15513/0182
DRUG PRODUCT
Description
The drug product is a drinkable solution, intended as a soothing formulation for people
having difficulties swallowing capsules. The drug product contains propylene glycol,
aspartame E951, opatint green dispersion, microcrystalline cellulose and carboxymethyl
cellulose, xanthan gum, glycerol, anhydrous citric acid, sodium benzoate E211 and
peppermint flavour.
Manufacture
A description and flow-chart of the manufacturing method has been provided. In-process
controls are appropriate considering the nature of the product and the method of manufacture.
Process validation has been carried out and the results are satisfactory.
Finished product specification
The finished product specification is satisfactory. Acceptance limits have been justified with
respect to conventional pharmaceutical requirements and, where appropriate, safety. Test
methods have been described and have been adequately validated, as appropriate. Batch data
have been provided and comply with the release specification. Certificates of analysis have
been provided for any working standards used.
Container Closure System
The solution is stored in 90 ml polypropylene bottles with child resistant cap and
polyethylene measuring cup.
Stability
Finished product stability studies have been conducted in accordance with current guidelines.
Based on the results, a shelf-life of 2 years has been set, which is satisfactory. There are no
special storage precautions.
Product literature
All product literature (SmPC, PIL and labelling) are satisfactory. The package leaflet was
submitted to the MHRA along with results of consultations with target patient groups ("user
testing"), in accordance with Article 59 of Council Directive 2001/83/EC. The results
indicate that the package leaflet is well-structured and organised, easy to understand and
written in a comprehensive manner. The test shows that the patients/users are able to act upon
the information that it contains.
Conclusion
From a quality point of view, it is recommended that a Marketing Authorisation is granted for
this application.
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UKPAR Imodium Liquid, 2 mg/15 ml Oral Solution
PL 15513/0182
NON-CLINICAL ASSESSMENT
No new non-clinical data have been supplied with this application and none are required for
an application of this type.
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PL 15513/0182
CLINICAL ASSESSMENT
INTRODUCTION
This formulation has been developed as an alternative Imodium formulation for patients who
prefer a liquid formulation.
Clinical Background
Loperamide is a synthetic piperidine which binds with high affinity to the µ-opiate receptor
in the myenteric plexus within the muscular layers of the intestinal wall. It acts by slowing
peristaltic activity, reducing intestinal motility and increasing mucosal contact time, allowing
more complete absorption of electrolytes and water. Loperamide also increases the tone of
the anal sphincter and inhibits fluid and electrolyte secretion in the small intestine. The net
result is firmer stool passed less frequently.
Proposed Indications
The following indications are proposed:
“For the symptomatic treatment of acute diarrhoea in adults and children aged 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.”
These indications are satisfactory.
Proposed Dose and Dose Regimen
The following posology is proposed:
“Acute diarrhoea:
Adults, the elderly, and children 12 years and over:
30 ml initially followed by 15 ml after every loose stool. The maximum daily dose should
not exceed 90 ml.
Symptomatic treatment of acute episodes of diarrhoea associated with irritable bowel
syndrome
Adults aged 18 years and over:
30 ml initially, followed by 15 ml after every loose stool, or as previously advised by your
doctor. The maximum daily dose should not exceed 90 ml.
Elderly:
No dose adjustment is required for the elderly.
Renal impairment:
No dose adjustment is required for patients with renal impairment.
Hepatic impairment:
Although no pharmacokinetic data are available in patients with hepatic impairment,
Imodium Liquid should be used with caution in such patients because of reduced first pass
metabolism (See 4.4 Special warnings and special precautions for use).
Method of administration: Oral use.”
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PL 15513/0182
This posology is satisfactory.
CLINICAL PHARMACOLOGY
Pharmacokinetics
Overview
The pharmacokinetics of loperamide have been well characterised. In summary, the half-life
is 10.8 hours with a range of 9-14 hours. It is well absorbed from the gut, but is almost
completely extracted and metabolised by the liver where it is conjugated and excreted via the
bile. Due to its high affinity for the gut wall and its high first pass metabolism, very little
loperamide reaches the systemic circulation. Most of the dose remains localised to the gut or
is metabolised during first-pass. About 1 % is systemically available after oral
administration. Excretion occurs mainly through the faeces. Less than 1 % of the dose is
excreted unchanged in the urine.
Bioequivalence
A single centre, randomised, single dose, open-label, two-period crossover bioequivalence
study was carried out. The proposed product (8 mg in 60 ml) and the reference product (4 x
2 mg capsules) were administered to healthy volunteers under fasting conditions. Thirty-two
subjects were enrolled and 30 subjects (15 male, 15 female) completed the trial.
The randomisation scheme is balanced for sequence and appears random.
The study objective was to evaluate the pharmacokinetic characteristics and bioequivalence
of the test formulation and the marketed reference formulation. The company has used a unit
dose which is double the recommended dose approved for Imodium to ensure sufficient
plasma levels for reliable quantification, given the low level of systemic exposure at
therapeutic dose.
Subjects were fasted for at least 10 hours prior to drug administration and for at least 4.5
hours after drug administration. The washout period between the two phases was 7 days. The
pharmacokinetic parameters to be derived were AUC0-t, AUC0-∞, Cmax, tmax, Kel, MRT and t1/2.
The protocol defines acceptance criteria for bioequivalence of 80 % - 125 % for both AUC
and Cmax.
In each study period, 16 blood samples were taken over 72 hours following dose
administration.
Concentrations of loperamide in plasma were measured using a validated chromatographic
assay. Pharmacokinetic parameters were calculated from plasma concentration data.
Population Studied
Thirty-two subjects were enrolled and randomised. Two subjects were withdrawn from the
study. One subject fainted following cannulation and the second patient was wheezing.
Thirty subjects completed the whole study.
Method of data analysis
Data were presented with 90 % confidence intervals and intra-individual coefficients of
variation. Comparisons of tmax, Kel, MRT and t1/2 were performed through descriptive
statistics. The area under the plasma concentration versus time curve was calculated using a
mixed log linear rule. Pharmacokinetic parameter calculations were conducted. ANOVA
were performed on ln values of Cmax, AUC0-t and AUC0-∞ of loperamide. ANOVA were also
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UKPAR Imodium Liquid, 2 mg/15 ml Oral Solution
PL 15513/0182
used to evaluate period, treatment and sequence effects. The arithmetic mean, geometric
mean, standard deviation, coefficient of variation, absolute minimum, maximum and median
were reported for each parameter.
Results
The primary objective of the study was to show bioequivalence of Imodium liquid and
Imodium capsules.
Log-transformed test/reference ratios with 90 % Confidence Intervals:
Arithmetic Mean (± SD)
Confidence intervals (%)
Imodium liquid
(treatment A)
Imodium capsule
(treatment B)
Point
estimate
Cmax(ng/ml)
2.16 (0.79)
2.20 (0.85)
99.10
AUC0-t
35.55 (13.28)
36.04 (14.14)
99.88
37.84 (14.39)
38.60 (15.16)
98.94
(ng/ml.h)
AUC0-∞
(ng/ml.h)
90 %
confidence
intervals
90.75108.21
93.36106.85
92.92105.35
There were no statistically significant treatment, sequence or period effects.
No deaths, serious or significant adverse events were reported during the study.
The study was carried out and the data analysed according to the protocol.
There were no subjects with positive plasma concentrations at the start of period two, so the
washout period was of adequate duration. Dropouts were handled according to study
protocol.
Conclusion
The use of loperamide as an anti-diarrhoeal agent is well established. The Clinical Overview
details the pharmacokinetics of loperamide, providing relevant bibliographic references on
the clinical pharmacology, efficacy and safety of loperamide hydrochloride.
The applicant has given an adequate description of the pharmacokinetics of loperamide to
determine that, although it acts locally, some drug is absorbed systemically for a reliable
assessment of bioavailability using a bioequivalence study. The bioequivalence study showed
the 90 % confidence interval for AUC and Cmax ratio for the reference and test products to be
within the acceptance range of 80 – 125 %. The result of this bioequivalence study is,
therefore, adequate to conclude that this oral solution of loperamide is bioequivalent to the
2 mg capsule.
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UKPAR Imodium Liquid, 2 mg/15 ml Oral Solution
PL 15513/0182
OVERALL CLINICAL CONCLUSION
Pharmacokinetics
The pharmacokinetic parameters obtained in this bioequivalence study are comparable for
both formulations.
Efficacy and safety
No new efficacy or safety data are presented. The applicant has referred to the well
established efficacy and safety of loperamide hydrochloride. The Overview provides a
comprehensive review of the published literature.
Risk Benefit
The safety and efficacy of loperamide hydrochloride in the management of diarrhoea is well
established. The applicant has provided a clinical study report of a bioequivalence study
which demonstrates bioequivalence between their proposed product and a licensed capsule
formulation of loperamide hydrochloride.
The Clinical Overview gives details on the clinical pharmacology, efficacy and safety of
loperamide hydrochloride with the appropriate references provided.
From a clinical point of view, it is recommended that a Marketing Authorisation is granted
for this application.
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UKPAR Imodium Liquid, 2 mg/15 ml Oral Solution
PL 15513/0182
OVERALL CONCLUSION AND RISK BENEFIT ASSESSMENT
QUALITY
The important quality characteristics of Imodium Liquid, 2 mg/15 ml oral solution are well
defined and controlled. The specifications and batch analytical results indicate consistency
from batch to batch. There are no outstanding quality issues that would have a negative
impact on the benefit/risk balance.
NON-CLINICAL
No new non-clinical data were submitted and none are required for applications of this type.
EFFICACY
The efficacy of loperamide hydrochloride is well established.
The SmPC, PIL and labelling are satisfactory and consistent with those for the
cross-reference product.
RISK BENEFIT ASSESSMENT
The quality of the product is acceptable, no significant non-clinical or clinical safety concerns
were identified, and benefit has been shown to be associated with loperamide hydrochloride.
The risk benefit is therefore considered to be positive.
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UKPAR Imodium Liquid, 2 mg/15 ml Oral Solution
PL 15513/0182
IMODIUM LIQUID, 2 MG/15 ML ORAL SOLUTION
PL 15513/0182
STEPS TAKEN FOR ASSESSMENT
1
2
3
4
5
6
7
The MHRA received the Marketing Authorisation application on 15 July 2008
Following standard checks and communication with the applicant the MHRA
considered the application valid on 17 July 2008.
Following assessment of the application the application was discussed by the
Commission on Human Medicines (CHM) on 12 March 2009
The applicant responded to the CHM’s requests, providing further information
on the dossier 8 October 2009
The applicant’s response was considered by the CHM and a request for further
information was sent on 18 February 2010
The applicant responded to the CHM’s requests, providing further information
on the dossier on 19 March 2010
The application was determined on 5 May 2010
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UKPAR Imodium Liquid, 2 mg/15 ml Oral Solution
PL 15513/0182
STEPS TAKEN AFTER AUTHORISATION – SUMMARY
The following table lists non-safety updates to the Marketing Authorisation for this product
that have been approved by the MHRA since the product was first licensed. The update has
been added as an annex to this PAR. This is not a complete list of the post-authorisation
changes that have been made to this Marketing Authorisation.
Date
submitted
28/08/2011
Application
type
Type II
Scope
Outcome
To harmonise the
maximum treatment period
for the currently approved
indications by changing it
for acute diarrhoea from 24
hours to 48 hours and for
IBS-related diarrhoea from
3 days to 48 hours.
Consequently, section 4.4
(Special warnings) of the
SmPC and PIL are
updated. There are also
some minor changes to the
PIL and labelling.
Approved 27/11/2011
19/05/2012
Type IB
To update section 5.2
(Pharmacokinetic
Properties) of the SmPC
in- line with reference
product 'Imodium Plus
caplets' (PL 15513/0342).
Approved 23/07/2012
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UKPAR Imodium Liquid, 2 mg/15 ml Oral Solution
PL 15513/0182
SUMMARY OF PRODUCT CHARACTERISTICS
1
NAME OF THE MEDICINAL PRODUCT
Imodium Liquid, 2 mg/ 15 ml oral solution
2
QUALITATIVE AND QUANTITATIVE COMPOSITION
Loperamide hydrochloride 2 mg per 15 ml.
Excipients include: Aspartame (E951)
For a full list of excipients, see section 6.1.
3
PHARMACEUTICAL FORM
Oral solution
Imodium Liquid is a green liquid.
4
4.1
CLINICAL PARTICULARS
Therapeutic indications
For the symptomatic treatment of acute diarrhoea in adults and children aged 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.
4.2
Posology and method of administration
Acute diarrhoea:
Adults, the elderly, and children 12 years and over:
30 ml initially followed by 15 ml after every loose stool. The maximum daily dose should not exceed
90 ml.
Symptomatic treatment of acute episodes of diarrhoea associated with irritable bowel syndrome
Adults aged 18 years and over:
30 ml initially, followed by 15 ml after every loose stool, or as previously advised by your doctor. The
maximum daily dose should not exceed 90 ml.
Elderly:
No dose adjustment is required for the elderly.
Renal impairment:
No dose adjustment is required for patients with renal impairment.
Hepatic impairment:
Although no pharmacokinetic data are available in patients with hepatic impairment, Imodium Liquid
should be used with caution in such patients because of reduced first pass metabolism. (see 4.4 Special
warnings and special precautions for use).
Method of administration: Oral use.
4.3
Contraindications
Imodium Liquid is contraindicated in patients with a known hypersensitivity to loperamide
hydrochloride or to any of the excipients.
Imodium Liquid should not be used in children less than 12 years of age.
Imodium Liquid 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, in particular:
•
•
•
•
When ileus or constipation are present or when abdominal distension develops, particularly in
severely dehydrated children
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
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Imodium Liquid should not be used alone in acute dysentery, which is characterised by blood in stools
and elevated body temperatures.
4.4
Special warnings and precautions for use
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
Imodium does not preclude the administration of appropriate fluid and electrolyte replacement therapy.
Since persistent diarrhoea can be an indicator of potentially more serious conditions, Imodium Liquid
should not be used for prolonged periods until the underlying cause of the diarrhoea has been
investigated.
Imodium Liquid must be used with caution when the hepatic function necessary for the drug’s
metabolism is defective (e.g. in cases of severe hepatic disturbance), as this might result in a relative
overdose leading to CNS toxicity.
Patients with AIDS treated with Imodium Liquid for diarrhoea should have therapy stopped at the
earliest signs of abdominal distension. There have been isolated reports of toxic megacolon in AIDS
patients with infectious colitis from both viral and bacterial pathogens treated with loperamide
hydrochloride.
If symptoms persist for more than 24 hours, patients should be advised to consult their physician.
Patients taking Imodium to control episodes of diarrhoea associated with Irritable Bowel Syndrome
previously diagnosed by a physician should be advised to return to their physician for medical advice if
their pattern of symptoms changes. Patients should also return to their physician if episodes of
diarrhoea continue for more than two weeks or there is a need for continued treatment of more than two
weeks.
Contains Aspartame (E951) a source of phenylalanine. May be harmful for people with
phenylketonuria.
Special Warnings to be included on the leaflet:
Only take Imodium 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 40 years or over and it is some time since your last attack of IBS or the 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, or if your symptoms worsen, or your symptoms
have not improved over two weeks.
4.5
Interaction with other medicinal products and other forms of interaction
Non-clinical data have shown that loperamide is a P-glycoprotein substrate. Concomitant
administration of loperamide (16 mg single dose) with quinidine, or ritonavir, which are both Pglycoprotein inhibitors, resulted in a 2 to 3-fold increase in loperamide plasma levels. The clinical
relevance of this pharmacokinetic interaction with P-glycoprotein inhibitors, when loperamide is given
at recommended dosages (2 mg, up to 16 mg maximum daily dose), is unknown.
4.6
Pregnancy and lactation
Safety in human pregnancy has not been established although studies in animals have not demonstrated
any teratogenic effects. As with other drugs, it is not advisable to administer loperamide in pregnancy.
Small amounts of loperamide may appear in human breast milk. Therefore loperamide is not
recommended during breast-feeding.
Women who are pregnant or breast-feeding should therefore be advised to consult their doctor for
appropriate treatment.
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4.7
Effects on ability to drive and use machines
Tiredness, dizziness, or drowsiness may occur when diarrhoea is treated with loperamide. Therefore, it
is advisable to use caution when driving a car or operating machinery. See Section 4.8 Undesirable
effects.
4.8
Undesirable effects
In clinical trials constipation and dizziness have been reported with greater frequency in loperamide
hydrochloride treated patients than placebo treated patients.
The following adverse experiences have also been reported, and within each system organ class, are
ranked by frequency, using the following convention: Very common (>1/10), Common (>1/100, <
1/10), Uncommon (> 1/ 1,000, < 1/100), Rare (>1/10,000, < 1/1,000), Very rare (<1/10,000), including
isolated reports.
Skin and subcutaneous tissue disorders
Very rare: rash, urticaria and pruritus. Isolated occurrences of angioedema, and bullous eruptions
including Stevens-Johnson Syndrome, erythema multiforme, and toxic epidermal necrolysis.
Immune system disorders
Very rare: isolated occurrences of allergic reactions and in some cases severe hypersensitivity reactions
including anaphylactic shock and anaphylactoid reactions.
Gastrointestinal Disorders
Very rare: abdominal pain, ileus, abdominal distension, nausea, constipation, vomiting, megacolon
including toxic megacolon, flatulence, and dyspepsia.
Renal and urinary disorders
Very rare: isolated reports of urinary retention.
Psychiatric system disorders
Very rare: drowsiness
Nervous system disorders
Very rare: Loss of consciousness, depressed level of consciousness, dizziness
A number of the adverse events reported during the clinical investigations and post-marketing
experience with loperamide are frequent symptoms of the underlying diarrhoeal syndrome (abdominal
pain/discomfort, nausea, vomiting, dry mouth, tiredness, drowsiness, dizziness, constipation, and
flatulence). These symptoms are often difficult to distinguish from undesirable drug effects.
4.9
Overdose
In case of overdose the following effects may be observed: constipation, urinary retention, ileus and
neurological symptoms (miosis, muscular hypertonia, somnolence and bradypnoea). If intoxication is
suspected, naloxone may be given as an antidote. Since the duration of action of loperamide is longer
than that of naloxone, the patient should be kept under constant observation for at least 48 hours in
order to detect any possible depression of the central nervous system. Children, and patients with
hepatic dysfunction, may be more sensitive to CNS effects. Gastric lavage, or induced emesis and or
enema or laxatives may be recommended.
5
5.1
PHARMACOLOGICAL PROPERTIES
Pharmacodynamic properties
Pharmacotherapeutic group: Antipropulsives; ATC Code: A07DA03
Loperamide binds to the opiate receptor in the gut wall, reducing propulsive peristalsis and increasing
intestinal transit time. Loperamide increases the tone of the anal sphincter.
In a double blind randomised clinical trial in 56 patients with acute diarrhoea receiving loperamide,
onset of anti-diarrhoeal action was observed within one hour following a single 4 mg dose. Clinical
comparisons with other anti-diarrhoeal drugs confirmed this exceptionally rapid onset of action of
loperamide.
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5.2
Pharmacokinetic properties
The half-life of loperamide in man is 10.8 hours with a range of 9 - 14 hours. Studies on distribution in
rats show high affinity for the gut wall with preference for binding to the receptors in the longitudinal
muscle layer. Loperamide is well absorbed from the gut, but is almost completely extracted and
metabolised by the liver where it is conjugated and excreted via the bile. Due to its high affinity for the
gut wall and its high first pass metabolism, very little loperamide reaches the systemic circulation.
5.3
Preclinical safety data
Acute and chronic studies on loperamide showed no specific toxicity. Results of in vivo and in vitro
studies carried out indicated that loperamide is not genotoxic. In reproduction studies, very high doses
(40mg/kg/day - 240 times the maximum human use level) loperamide 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.
6
6.1
PHARMACEUTICAL PARTICULARS
List of excipients
Propylene glycol
Aspartame E951
Opatint green dispersion
Microcrystalline cellulose and carboxymethyl cellulose
Xanthan gum
Glycerol
Anhydrous citric acid
Sodium benzoate E211
Peppermint flavour.
6.2
Incompatibilities
In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal
products.
6.3
Shelf life
2 years unopened. 12 months opened.
6.4
Special precautions for storage
This medicinal product does not require any special storage conditions.
6.5
Nature and contents of container
Polypropylene bottle with child resistant cap and polyethylene measuring cup.
Pack size: 90 ml.
6.6
Special precautions for disposal
No special requirements
7
MARKETING AUTHORISATION HOLDER
McNeil Products Ltd.
Foundation Park
Roxborough Way
Maidenhead
Berkshire SL6 3UG
UK
8
MARKETING AUTHORISATION NUMBER(S)
PL 15513/0182
9
DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
05/05/2010
10
DATE OF REVISION OF THE TEXT
05/05/2010
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PL 15513/0182
PATIENT INFORMATION LEAFLET
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PL 15513/0182
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UKPAR Imodium Liquid 2 mg/15 ml oral solution
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LABELLING
Label:
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UKPAR Imodium Liquid 2 mg/15 ml oral solution
PL 15513/0182
Carton:
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UKPAR Imodium Liquid 2 mg/15 ml oral solution
PL 15513/0182
Annex I
Reference:
PL 15513/0182-variation 0004
Product:
Imodium Liquid 2 mg/15 ml oral solution (GSL)
Marketing Authorisation Holder: McNeil Products Limited
Active Ingredient(s):
Loperamide hydrochloride
Reason
To harmonise the maximum treatment period for both indications, before patients must
consult a doctor i.e. change acute diarrhoea from 24 hours to 48 hours, and IBS-related
diarrhoea from 3 days to 48 hours.
Evaluation
The first amendment to Section 4.4 proposes to increase the period of self-medication in
acute diarrhoea from 24 to 48 hours before medical advice is sought. This is not likely to
represent a significant safety concern provided ‘red flag’ symptoms are not present. Such
symptoms are covered by the contraindications and special warnings. The SmPC and PIL
highlight the importance of rehydration, particularly in children and frail or elderly patients,
and the products are not licensed for use in children under the age of 12 years. This
amendment also aligns the duration of use in the UK with that in the rest of the world.
The second amendment to Section 4.4 proposes to decrease the period of self-medication in
IBS-associated diarrhoea from 3 to 2 days, and clarifies the need to visit the physician if
episodes of diarrhoea continue for more than 2 weeks. This amendment harmonises the
period of self-medication with that for acute diarrhoea, and is endorsed.
Satisfactory, updated SmPC fragment was submitted in support of the variation application.
The variation was approved on 27 November 2011 and the following updated SmPC
fragment, PIL and labelling have been incorporated into the Marketing Authorisation.
Conclusion
The proposed amendments to the SmPC, PIL and labelling are acceptable, and clarify the use
of the products for patients, without altering the benefit-risk balance.
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UKPAR Imodium Liquid 2 mg/15 ml oral solution
PL 15513/0182
Summary of Product Characteristics - updated
The SmPC fragment updated in-line with the variation is reproduced below:
4.4
Special warnings and precautions for use
Treatment of diarrhoea with Imodium Liquid 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, Imodium
Liquid 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 loperamide hydrochloride should be discontinued and patients should be advised to consult
their doctor.
Patients with AIDS treated with Imodium Liquid 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 loperamide 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.
Contains Aspartame (E951) a source of phenylalanine. May be harmful for people with
phenylketonuria.
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 loperamide 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.
Special Warnings to be included on the leaflet:
Only take Imodium Liquid 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, or if your symptoms worsen, or your
symptoms have not improved over two weeks.
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UKPAR Imodium Liquid 2 mg/15 ml oral solution
PL 15513/0182
Patient Information Leaflet – updated
The following text is the approved Patient Information Leaflet (PIL) text. No
PIL mock-ups have been provided. In accordance with medicines legislation, the
product shall not be marketed in the UK until approval of the PIL mock-ups has
been obtained.
Imodium®
Liquid
loperamide
This medicine is used for two different types of diarrhoea.
They have different age limits.
. See Section 1
Do not take this medicine:
There are some people who should not use this
medicine. To find out if you are one of them, see Section 2
If you have ever had a bad reaction to any of the
ingredients. For the list of ingredients, see Section 6
Speak to your doctor:
If you suffer from any of the conditions mentioned in
Section 2
If you are taking any other medicines. See Section 2
If you have Irritable Bowel Syndrome (IBS) see also
Section 2 Extra warnings for IBS patients
Follow the dosage instructions carefully. See Section 3
Now read this whole leaflet carefully before you use this
medicine. Keep the leaflet: you might need it again.
1 What the medicine is for
Imodium Liquid is used to treat two types of diarrhoea.
The two types have different age limits.
Short-term diarrhoea
For adults and children aged 12 and over.
To treat attacks that last up to 48 hours.
If your attack lasts longer than 48 hours, talk to your doctor.
IBS diarrhoea
For adults and young people aged 18 and over
who have been diagnosed with IBS (Irritable Bowel Syndrome).
To treat attacks that last up to 48 hours.
You can use this medicine for up to 2 weeks for
repeated attacks, but if any one attack lasts continuously
for longer than 48 hours, talk to your doctor.
The liquid contains loperamide hydrochloride, a substance
that helps reduce diarrhoea by slowing down an overactive
bowel. This allows water and salts that are usually lost in
diarrhoea to be absorbed by the body.
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UKPAR Imodium Liquid 2 mg/15 ml oral solution
PL 15513/0182
2 Before taking this medicine
Warnings for everyone
This medicine is suitable for most people, but a few people
should not use it:
Do not take this medicine…
If you have ever had a bad reaction to any of the ingredients.
If it is for a child aged under 12 (or under 18 for an
IBS patient).
If you have severe diarrhoea after taking antibiotics.
If you are having a flare-up of an inflammatory bowel
condition like ulcerative colitis.
If you are constipated, or your stomach appears swollen
(especially in children with severe dehydration).
If you have acute dysentery, the symptoms of which may
include blood in your stools and a high temperature.
If any of these applies to you, talk to a doctor or pharmacist
and do not take Imodium.
Talk to your doctor first…
If you have AIDS and your stomach becomes swollen,
stop taking the tablets immediately and contact your doctor.
If you suffer from liver disease.
If you have diarrhoea that lasts for more than 48 hours.
If you have severe diarrhoea as your body loses more
fluid, sugars and salts than normal.
If you are taking any other medicines, including:
ritonavir (used to treat HIV)
quinidine (used to treat abnormal heart rhythms or malaria)
oral desmopressin (used to treat excessive urination).
itraconazole or ketoconazole (used to treat fungal infections)
gemfibrozil (used to treat high cholesterol)
If you are unsure about any of the medicines you are taking,
show the bottle or pack to your pharmacist.
If any of these applies to you (now or in the past), talk to a doctor
or pharmacist.
Pregnancy or breast-feeding
If you are pregnant, think you are pregnant or planning a
pregnancy: ask your doctor or pharmacist for advice before
taking this medicine.
If you are breast-feeding do not take this medicine. Small
amounts may get into your milk. Talk to your doctor about a
suitable treatment.
Special warnings about this medicine
This medicine may make you feel dizzy, tired or sleepy.
You may feel less alert, feel faint or pass out. If you’re
affected do not drive or use machines.
Your body can lose large amounts of fluids and salts when
you have diarrhoea. You need to replace the fluid by
drinking more liquid than usual. Ask your pharmacist about
rehydration therapy to replace lost salts. This is especially
important for children, and frail or older people.
Some of the ingredients can cause problems
Aspartame (E951) contains a source of phenylalanine.
This may be harmful for people with phenylketonuria.
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UKPAR Imodium Liquid 2 mg/15 ml oral solution
PL 15513/0182
Extra warnings for IBS patients
Use only if your doctor has previously diagnosed IBS.
Check the following:
Do not take this medicine…
If you are aged under 18.
Talk to your doctor first…
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.
If any of these applies to you, talk to your doctor before
taking Imodium.
3 How to take this medicine
Check the tables below to see how much medicine to take.
For oral use only.
Do not use more than the dose shown in the tables.
The liquid is not for long-term treatment.
Short-term diarrhoea
Age
Dose
Adults and children
aged 12 and over
Take 30 ml (2 measuring cup doses) to start treatment
Take 15 ml (1 measuring cup dose) after each loose
bowel movement
Do not take for attacks lasting longer than 48 hours.
Do not take more than 90 ml (6 measuring cup doses) in a 24-hour period.
Replace lost fluid by drinking more liquid than usual.
Not for children aged under 12.
How long to take Imodium for short-term
diarrhoea
You can use this medicine for up to 48 hours.
If your attack lasts longer than 48 hours, stop taking Imodium
and talk to your doctor.
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UKPAR Imodium Liquid 2 mg/15 ml oral solution
PL 15513/0182
IBS diarrhoea
Age
Dose
Adults aged 18 and over
Take 30 ml (2 measuring cup doses) to
start treatment
Take 15 ml (1 measuring cup dose) after
each loose bowel movement (or as advised
by your doctor)
You can use this medicine for up to 2 weeks for repeated
attacks, but do not take for any one attack lasting longer
than 48 hours.
Do not take more than 90 ml (6 measuring cup doses) in a 24-hour period.
Replace lost fluid by drinking more liquid than usual.
Not for children and young people aged under 18.
Talk to your doctor and stop taking this medicine:
If you have been using this medicine continuously for 48 hours.
If you develop new IBS symptoms.
If your IBS symptoms get worse.
If your IBS symptoms have not improved after 2 weeks.
How long to take Imodium for IBS diarrhoea
You can use this medicine for up to 2 weeks for
repeated attacks of IBS diarrhoea. But if any one attack lasts
for longer than 48 hours, stop taking Imodium and talk to
your doctor.
If anyone takes too much of this medicine
If anyone takes too much Imodium liquid, contact your
doctor or nearest Accident and Emergency department
taking this bottle with you.
If you forget to take the medicine
You should only take this medicine as you need it, following
the dosage instructions above carefully.
If you forget to take a dose, take a dose after the next loose
stool (bowel movement). Do not take a double dose.
4 Possible side-effects
Imodium can have side-effects, like all medicines, although
these don’t affect everyone and most are usually mild.
Get medical help at once
Rare: (affects less than 1 in 1,000 but 1 or more in 10,000 people)
Allergic reactions including unexplained wheezing, shortness
of breath, passing out or swelling of face and throat.
Skin rashes, which may be severe and include blistering or
peeling skin.
Loss of consciousness or reduced level of consciousness
(passing out, feeling faint or less alert), uncoordinated
movements.
If you get any of these, stop using the medicine and get
medical help at once.
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UKPAR Imodium Liquid 2 mg/15 ml oral solution
PL 15513/0182
Talk to a doctor as soon as possible
Uncommon: (affects less than 1 in 100 but 1 or more in 1,000 people)
Itchiness or hives.
Stomach pain or swollen stomach.
Rare: (affects less than 1 in 1,000 but 1 or more in 10,000 people)
Difficulties passing water.
Severe constipation.
Miosis (narrowing of the pupils of the eye).
If you notice any of the above, stop using the medicine and
talk to a doctor.
Other effects that may occur
Common: (affects less than 1 in 10 but 1 or more in 100 people)
Feeling sick, constipation or wind
Headache
Uncommon: (affects less than 1 in 100 but 1 or more in 1,000 people)
Dizziness or drowsiness
Vomiting, indigestion
Dry mouth
Rare: (affects less than 1 in 1,000 but 1 or more in 10,000 people)
Tiredness.
If you experience any side-effects not included in this leaflet or
are not sure about anything, talk to your doctor or pharmacist.
5 Storing this medicine
Keep the product out of the reach and sight of children.
There are no special storage conditions. Use within 6 months of opening.
Do not use your medicine after the date shown as the
expiry date on the packaging.
6 Further information
What’s in this medicine
The active ingredient in Imodium Liquid is: Loperamide
hydrochloride 2 mg per 15 ml.
Other ingredients are: Propylene glycol, aspartame (E951), Opatint green
dispersion, microcrystalline cellulose and carboxymethylcellulose, xanthan
gum, glycerol, citric acid, sodium benzoate (E211), peppermint flavour and
purified water.
What the medicine looks like
Imodium Liquid is a green oral liquid available in 90 ml bottles.
Product Licence holder: McNeil Products Ltd, Maidenhead,
Berkshire, SL6 3UG, UK.
Manufacturer: Janssen Pharmaceutica NV, Turnhoutseweg 30, B2340,
Beerse, Belgium.
This leaflet was revised October 2011.
Imodium is a registered trade mark
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UKPAR Imodium Liquid 2 mg/15 ml oral solution
PL 15513/0182
Labelling – updated
The following text is the approved label text. No label mock-ups have been
provided. In accordance with medicines legislation, the product shall not be
marketed in the UK until approval of the label mock-ups has been obtained.
Imodium® Liquid
Loperamide hydrochloride
Fresh mint flavour
Soothing relief from diarrhoea
90 ml e
Each 15ml contains 2mg loperamide hydrochloride. Also contains E951
Dosage: Short-term diarrhoea: Adults and children over 12 years: Take 30 ml to start treatment. Take 15 ml
after each loose bowel movement, up to a maximum of 90 ml per day. If your diarrhoea lasts for more than 48
hours, consult your doctor. Not recommended for children under 12 years.
IBS diarrhoea, previously diagnosed by a doctor: Adults aged 18 years and over: Take 30 ml to start
treatment. Take 15 ml after each loose bowel movement, or as previously advised by a doctor, up to a
maximum of 90 ml per day. You can use this medicine for up to 2 weeks for repeated attacks, but do not take
for any one attack lasting longer than 48 hours. If your symptoms change, worsen or are not improved after 2
weeks, consult your doctor.
Read the leaflet before use.
Keep out of the reach and sight of children.
McNeil Products Limited, Maidenhead, Berkshire, SL6 3UG, UK
OPEN HERE
PL 15513/0182
Stamping area for
Batch No/Expiry date
Barcode Decision-Approved 27/11/2011.
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UKPAR Imodium Liquid 2 mg/15 ml oral solution
PL 15513/0182
Annex II
Product Licence Number:
PL 15513/0182 - 0006
Product:
Imodium Liquid 2 mg/15 ml Oral Solution
Marketing Authorisation Holder:
McNeil Products Limited
Active Ingredient(s):
Loperamide hydrochloride
Reason:
To update Section 5.2 (Pharmacokinetic Properties) of the SmPC in line with
reference product 'Imodium Plus Caplets' (PL 15513/0342).
Supporting Evidence
In this National Type IB variation application, the applicant has proposed to change
Section 5.2 (Pharmacokinetic Properties) to bring it into line with 'Imodium Plus
Caplets' (PL 15513/0342).
The applicant has submitted:
- Current and proposed SmPC
Evaluation
The proposed SmPC with amendments to Section 5.2 provided by the MAH is
considered satisfactory.
THE FINAL APPROVED SMPC FRAGMENT, 5.2 (PHARMACOKINETIC
PROPERTIES) FOR BOTH IMODIUM CLASSIC 2MG CAPSULES AND IMODIUM
ORIGINAL 2MG CAPSULES IS PRESENTED BELOW:
5.2
Pharmacokinetic properties
Absorption: Most ingested loperamide 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 loperamide is 95%, mainly to albumin. Non-clinical data have
shown that loperamide is a P-glycoprotein substrate.
Metabolism: loperamide is almost completely extracted by the liver, where it is
predominantly metabolized, conjugated and excreted via the bile. Oxidative Ndemethylation is the main metabolic pathway for loperamide, 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 loperamide in man is about 11 hours with a range
of 9-14 hours. Excretion of the unchanged loperamide and the metabolites
mainly occurs through the faeces.
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UKPAR Imodium Liquid 2 mg/15 ml oral solution
PL 15513/0182
Conclusion
The proposed SmPC is acceptable.
Decision
PL 15513/0182 - 0006: Approved 23/07/2012
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