Fromilid uno, 500 mg 14 pcs

Pharmacological action Pharmacological action – antibacterial.
Pharmacodynamics

Clarithromycin is a semi-synthetic antibiotic of macrolide group and has antibacterial action by interacting with 50S ribosomal subunit and inhibiting protein synthesis of bacteria sensitive to it.

Clarithromycin has demonstrated high activity under in vitro conditions against both standard laboratory strains of bacteria and those isolated from patients in clinical practice. It shows high activity against many aerobic and anaerobic gram-positive and gram-negative microorganisms. Minimum inhibitory concentrations (MIC) of clarithromycin for most pathogens are lower than MIC of erythromycin, on average, by one log2 dilution.

Clarithromycin is highly active against Legionella pneumophila, Mycoplasma pneumoniae under in vitro conditions. It has a bactericidal effect against Helicobacter pylori; this activity of clarithromycin is higher at neutral pH than at acidic pH.

In addition, in vitro and in vivo data indicate that clarithromycin is active against clinically relevant mycobacterial species. Enterobacteriaceae and Pseudomonas spp. as well as other non-lactose-fermenting Gram-negative bacteria are not sensitive to clarithromycin.

The activity of clarithromycin against most strains of the microorganisms listed below has been demonstrated both in vitro and in clinical practice for the diseases listed under “Indications”.

Aerobic gram-positive microorganisms: Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus pyogenes, Listeria monocytogenes.

Aerobic gram-negative microorganisms: Haemophilus influenzae, Haemophilus parainfluenzae, Moraxella catarrhalis, Neisseria gonorrhoeae, Legionella pneumophila.

Other microorganisms: Mycoplasma pneumoniae, Chlamydia pneumoniae (TWAR).

Mycobacteria: Mycobacterium leprae, Mycobacterium kansasii, Mycobacterium chelonae, Mycobacterium fortuitum, Mycobacterium avium complex (MAC) – complex including: Mycobacterium avium, Mycobacterium intracellulare.

The production of beta-lactamase has no effect on clarithromycin activity. Most staphylococcal strains resistant to methicillin and oxacillin are also resistant to clarithromycin.

Helicobacter pylori. Sensitivity of Helicobacter pylori to clarithromycin was studied in Helicobacter pylori isolates isolated from 104 patients before the start of therapy with the drug. Clarithromycin-resistant Helicobacter pylori strains were isolated in 4 patients, moderately resistant strains were isolated in 2 patients, and the remaining 98 patients had Helicobacter pylori isolates sensitive to clarithromycin.

Clarithromycin has action in vitro and against most strains of the following microorganisms (but the safety and efficacy of clarithromycin in clinical practice has not been confirmed by clinical studies, and the practical value remains unclear):

Aerobic gram-positive microorganisms: Streptococcus agalactiae, Streptococci (groupsC, F, G), Viridans group streptococci.

Aerobic gram-negative microorganisms: Bordetella pertussis, Pasteurella multocida.

Anaerobic gram-positive microorganisms: Clostridium perfringens, Peptococcus niger, Propionibacterium acnes.

Anaerobic gram-negative microorganisms: Bacteroides melaninogenicus.

Spirochetes: Borrelia burgdorferi, Treponema pallidum.

Campylobacter: Campilobacter jejuni.

The main metabolite of clarithromycin in humans is the microbiologically active metabolite 14-hydroxyclarithromycin (14-OH-clarithromycin).

The microbiological activity of the metabolite is the same as that of the parent substance, or 2 times weaker against most microorganisms. The exception is Haemophilus influenzae, against which the effectiveness of the metabolite is twice as high. The parent compound and its main metabolite have either additive or synergistic effects against Haemophilus influenzae under in vitro and in vivo conditions depending on the bacterial strain.

Pharmacokinetics

Intake. The drug is rapidly absorbed in the gastrointestinal tract. Absolute bioavailability is about 50%. There was practically no cumulation when taking repeated doses of the drug, and the character of metabolism in human body did not change.

Distribution, metabolism and excretion

In vitro. Clarithromycin binds to blood plasma proteins by 70% at concentrations from 0.45 to 4.5 µg/ml. At a concentration of 45 µg/ml, the binding decreases to 41%, probably as a result of saturation of the binding sites.

This is observed only at concentrations many times greater than the therapeutic concentration.

Healthy. In patients taking 500 mg of clarithromycin once daily after a meal, the Cmax of clarithromycin and 14-OH-clarithromycin in plasma was 1.3 and 0.48 µg/mL, respectively. T1/2 of clarithromycin and the metabolite were 5.3 and 7.7 h, respectively. When a single dose of clarithromycin in the dosage form – sustained release film-coated tablets, 1000 mg (2 × 500 mg), the Cmax of clarithromycin and its hydroxylated metabolite in plasma was 2.4 and 0.67 µg/ml, respectively.

The T1/2 of clarithromycin was 5.8 h when administered at a dose of 1000 mg, compared with 8.9 h for 14-OH clarithromycin. Tmax with oral administration of both 500 and 1000 mg of clarithromycin was approximately 6 h. The Cmax of 14-OH-clarithromycin did not increase in proportion to the oral dose of clarithromycin, while the T1/2 of both clarithromycin and its hydroxylated metabolite tended to lengthen with increasing dose. This nonlinear pharmacokinetics of clarithromycin combined with decreased formation of 14-hydroxylated and N-demethylated products at high doses indicates a nonlinear metabolism of clarithromycin that becomes more pronounced at higher doses.

The kidneys excrete approximately 40% of the oral dose of clarithromycin; the intestines excrete approximately 30%.

Patients. Clarithromycin and its metabolite (14-OH clarithromycin) are rapidly absorbed into tissues and body fluids. There is limited evidence that the concentration of clarithromycin in cerebrospinal fluid when ingested is negligible (i.e., only 1-2% of the serum concentration with normal blood-brain barrier permeability). Concentrations in tissues are usually several times higher than in serum.

Liver function impairment. No dose adjustment of clarithromycin is required in patients with moderate to severe hepatic impairment but with preserved renal function. Plasma Css and systemic clearance of clarithromycin do not differ between patients in this group and healthy patients. Css of 14-OH clarithromycin is lower in patients with liver dysfunction than in healthy patients.

Renal dysfunction. Impaired renal function increases plasma Cmax and Cmin of clarithromycin, T1/2, AUC of clarithromycin and its metabolite (14-OH clarithromycin). The elimination constant and renal excretion decreases. The degree of change in these parameters depends on the degree of renal impairment.

In elderly patients. In elderly patients, plasma concentrations of clarithromycin and its metabolite (14-OH clarithromycin) were higher and excretion slower than in the younger group. However, after adjustment for renal creatinine clearance, there were no differences in the two groups. Thus, the main influence on the pharmacokinetic parameters of clarithromycin is renal function, not age.

Indications

Active ingredient

Composition

How to take, the dosage

Adults and children over 12 years of age – 1 tablet (500 mg) once a day.

In tonsillitis and otitis media: Adults and children over 18 years of age – 1 tablet (500 mg) once a day.

In severe infections, the dose is increased to 2 tablets (1000 mg) once a day.

The usual length of treatment is from 5 to 14 days. The exceptions are community-acquired pneumonia and sinusitis, which require 6 to 14 days of treatment.

Renal dysfunction. In patients with severe renal insufficiency (creatinine Cl less than 30 ml/min) the preparation Fromilide® uno is contraindicated. In patients with moderate renal impairment (creatinine Cl between 30 and 60 ml/min) the preparation dose is reduced twice as much, which is not more than 500 mg (1 tablet) per day.

Interaction

The use of the following drugs concomitantly with clarithromycin is contraindicated due to the possibility of serious side effects

Cisapride, pimozide, terfenadine and astemizole. Concomitant administration of clarithromycin with cisapride, pimozide, terfenadine or astemizole has been reported to increase plasma concentrations of the latter, which may lead to prolongation of the QT interval on ECG and to cardiac arrhythmias, including ventricular tachycardia (including pirouette ventricular tachycardia) and ventricular fibrillation (see Contraindications).

A ergot alkaloids. Post-marketing studies indicate that concomitant use of clarithromycin with ergotamine or dihydroergotamine may cause the following effects associated with acute poisoning with ergotamines: vasospasm, ischemia of the extremities and other tissues, including the CNS. Concomitant use of clarithromycin and ergot alkaloids is contraindicated (see “Contraindications”).

HMG-CoA reductase inhibitors (statins). Concomitant use of clarithromycin with lovastatin or simvastatin is contraindicated (see “Contraindications”) due to the fact that these statins are largely metabolized by CYP3A4 isoenzyme, and simultaneous use with clarithromycin increases their serum concentrations, which leads to increased risk of myopathy, including rhabdomyolysis. Rhabdomyolysis has been reported in patients taking clarithromycin concomitantly with these drugs. If clarithromycin should be used, lovastatin or simvastatin should be discontinued for the duration of therapy. Clarithromycin should be used with caution in case of combined therapy with other statins. It is recommended to use statins whose metabolism does not depend on CYP3A isoenzyme (e.g., fluvastatin). In case of necessity of concomitant administration, it is recommended to take the lowest dose of statin. The development of signs and symptoms of myopathy should be controlled.

The effect of other drugs on clarithromycin

Drugs that are inducers of the CYP3A isoenzyme (e.g. rifampicin, phenytoin, carbamazepine, phenobarbital, St. John’s wort) may induce the metabolism of clarithromycin. This can lead to subtherapeutic concentrations of clarithromycin and, consequently, a decrease in its efficacy. In addition, it is necessary to monitor the plasma concentration of CYP3A isoenzyme inducer, which may increase due to inhibition of CYP3A isoenzyme by clarithromycin. Concomitant use of rifabutin and clarithromycin resulted in increased concentrations of rifabutin and decreased plasma concentrations of clarithromycin with increased risk of uveitis.

The following drugs have proven or suspected effects on plasma concentrations of clarithromycin, dosage adjustment or switch to alternative treatment may be required if used concomitantly with clarithromycin

Efavirenz, nevirapine, rifampicin, rifabutin and rifapentin. Strong cytochrome P450 inducers such as efavirenz, nevirapine, rifampicin, rifabutin and rifapentine can accelerate the metabolism of clarithromycin and thus decrease the plasma concentration of clarithromycin and weaken therapeutic effect, while increasing the plasma concentration of 14-OH clarithromycin, a metabolite that is also microbiologically active. Since microbiological activity of clarithromycin and 14-OH clarithromycin differs with respect to different bacteria, the therapeutic effect may be reduced when clarithromycin and cytochrome P450 system inducers are used concomitantly.

Etravirin. Plasma concentrations of clarithromycin are decreased when concomitant use with etravirine, but plasma concentrations of the active metabolite 14-OH-clarithromycin are increased. Since 14-OH-clarytromycin has low activity against MAC infections, the overall activity against these pathogens may be altered, so alternative treatment should be considered for MAC treatment.

Fluconazole. Concomitant administration of fluconazole at a dose of 200 mg daily and clarithromycin at a dose of 500 mg twice daily in 21 healthy volunteers resulted in a 33% and 18% increase in the mean minimum Css and AUC of clarithromycin, respectively. At the same time, concomitant administration had no significant effect on the mean Css of the active metabolite 14-OH clarithromycin. No dose adjustment of clarithromycin is required if fluconazole is concomitantly administered.

Ritonavir. A pharmacokinetic study has shown that concomitant administration of ritonavir at a dose of 200 mg every 8 hours and clarithromycin at a dose of 500 mg every 12 hours resulted in a marked inhibition of clarithromycin metabolism. Concomitant administration of ritonavir increased the Cmax of clarithromycin by 31%, the Cmin increased by 182%, and the AUC increased by 77%. Complete inhibition of 14-OH clarithromycin formation was noted. Due to the wide therapeutic range of clarithromycin, no dose reduction is required in patients with normal renal function. In patients with renal impairment, it is advisable to consider the following dose adjustments: at Cl creatinine 30-60 ml/min, the dose of clarithromycin should be reduced by 50%. Ritonavir should not be taken concomitantly with clarithromycin in doses greater than 1 g/day.

The effect of clarithromycin on other drugs

The antiarrhythmic drugs (quinidine and disopyramide). Ventricular pirouette tachycardia may occur when clarithromycin and quinidine or disopyramide are used concomitantly. If clarithromycin is concomitantly administered with these drugs, regular ECG monitoring for QT interval prolongation should be performed, and serum concentrations of these drugs should be monitored.

Disopyramide. Cases of hypoglycemia have been reported with clarithromycin and disopyramide concomitantly in postmarketing use. Blood glucose concentrations should be monitored when using clarithromycin and disopyramide concomitantly.

Hypoglycemic agents for oral administration/insulin. Concomitant use of clarithromycin and oral hypoglycemic agents (e.g. sulfonylurea derivatives) and/or insulin may cause severe hypoglycemia. Concomitant use of clarithromycin with some hypoglycemic drugs (e.g. nateglinide, pioglitazone, repaglinide and rosiglitazone) may lead to inhibition of CYP3A isoenzyme by clarithromycin, which may result in hypoglycemia. Close monitoring of blood glucose concentration is recommended.

CYP3A isoenzyme-dependent interactions

Simultaneous administration of clarithromycin, which is known to inhibit the CYP3A isoenzyme, and drugs primarily metabolized by CYP3A isoenzyme may be associated with a mutual increase in their concentrations, which may enhance or prolong both therapeutic and adverse effects. Clarithromycin should be used with caution in patients receiving drugs that are substrates of CYP3A isoenzyme, especially if these drugs have a narrow therapeutic range (e.g. carbamazepine), and/or drugs that are extensively metabolized by this isoenzyme. Dose adjustments should be made if necessary for drugs taken concomitantly with clarithromycin. Serum concentrations of drugs that are primarily metabolized by CYP3A isoenzyme should also be monitored if possible.

The following drugs/classes are metabolized by the same CYP3A isoenzyme as clarithromycin: alprazolam, carbamazepine, cilostazol, cyclosporine, disopyramide, methylprednisolone, midazolam, omeprazole, indirect anticoagulants (e.g. warfarin), atypical neuroleptics (e.g. quetiapine), quinidine, rifabutin, sildenafil, tacrolimus, triazolam and vinblastine. CYP3A inhibitors also include the following drugs that are contraindicated for concomitant use with clarithromycin: astemizole, cisapride, pimozide, terfenadine, lovastatin, simvastatin and ergot alkaloids (see “Contraindications”). Drugs that interact similarly through other isoenzymes within the cytochrome P450 system include: phenytoin, theophylline and valproic acid.

Indirect anticoagulants. Concomitant administration of warfarin and clarithromycin may cause bleeding, marked increase in INR and prolongation of PV. In case of concomitant use with warfarin or other indirect anticoagulants, it is necessary to monitor INR and PV.

Omeprazole. Clarithromycin (500 mg every 8 hours) has been studied in healthy adult volunteers in combination with omeprazole (40 mg daily). When clarithromycin and omeprazole were used concomitantly, plasma Css of omeprazole were increased (Cmax, AUC0-24 and T1/2 increased by 30, 89 and 34%, respectively). The mean gastric pH over 24 h was 5.2 (when omeprazole was taken alone) and 5.7 (when omeprazole was taken simultaneously with clarithromycin).

Sildenafil, tadalafil, and vardenafil. Each of these FDE inhibitors is metabolized at least in part with the CYP3A isoenzyme. At the same time, the CYP3A isoenzyme may be inhibited in the presence of clarithromycin. Concomitant use of clarithromycin with sildenafil, tadalafil or vardenafil may lead to increased inhibitory effects on FDE When these drugs are used concomitantly with clarithromycin, a dose reduction of sildenafil, tadalafil and vardenafil should be considered.

Theophylline, carbamazepine. Concomitant use of clarithromycin and theophylline or carbamazepine may increase concentrations of these drugs in the systemic blood stream.

Tolterodine. The primary metabolism of tolterodine is through the CYP2D6 isoenzyme. However, in a portion of the population lacking the CYP2D6 isoenzyme, metabolism occurs via the CYP3A isoenzyme. In this population, suppression of the CYP3A isoenzyme leads to significantly higher serum concentrations of tolterodine. In a population with low levels of metabolism via the CYP2D6 isoenzyme, a dose reduction of tolterodine may be required with concomitant use of CYP3A isoenzyme inhibitors such as clarithromycin.

Benzodiazepines (e.g., alprazolam, midazolam, triazolam). Concomitant use of midazolam and clarithromycin tablets (500 mg twice daily) showed a 2.7-fold increase in the AUC of midazolam after IV administration of midazolam and a 7-fold increase after oral administration. Concomitant use of clarithromycin with oral midazolam is contraindicated. If simultaneously with clarithromycin midazolam in dosage form for IV administration is used, the patient’s condition should be carefully monitored for possible adjustment of the dose of midazolam. The same precautions should be applied to other benzodiazepines that are metabolized by the CYP3A isoenzyme, including triazolam and alprazolam. For benzodiazepines whose excretion is not dependent on CYP3A isoenzyme (temazepam, nitrazepam, lorazepam), a clinically significant interaction with clarithromycin is unlikely.

Concomitant use of clarithromycin and triazolam may cause CNS effects such as drowsiness and confusion. Therefore, it is recommended to monitor for CNS disturbance symptoms if used concomitantly.

Interactions with other drugs

Aminoglycosides. When concomitant administration of clarithromycin with other ototoxic drugs, especially aminoglycosides, care should be taken and vestibular and auditory functions should be monitored both during and after therapy.

Colchicine. Colchicine is a substrate of both the CYP3A isoenzyme and the carrier protein P-glycoprotein (Pgp). Clarithromycin and other macrolides are known to be CYP3A and Pgp isoenzyme inhibitors. If clarithromycin and colchicine are used concomitantly, inhibition of Pgp and/or CYP3A isoenzyme may lead to increased effect of colchicine. The development of clinical symptoms of colchicine poisoning should be controlled. There have been post-marketing reports of cases of colchicine poisoning when concomitantly administered with clarithromycin, more often in elderly patients. Some of the described cases occurred in patients with renal insufficiency. Some cases have been reported to be fatal. Concomitant use of clarithromycin and colchicine is contraindicated (see Contraindications).

Digoxin. Digoxin is believed to be a substrate of Pgp. Clarithromycin is known to inhibit Pgp. When clarithromycin and digoxin are used concomitantly, the inhibition of Pgp by clarithromycin may increase the effect of digoxin. Concomitant administration of digoxin and clarithromycin may also lead to increased serum concentrations of digoxin. Clinical symptoms of digoxin poisoning, including potentially fatal arrhythmias, have been reported in some patients. Serum digoxin concentrations should be closely monitored when clarithromycin and digoxin are taken concomitantly.

Zidovudine. Simultaneous oral administration of clarithromycin tablets and zidovudine in HIV-infected adults may result in decreased plasma Css of zidovudine. Because clarithromycin affects oral absorption of zidovudine, interactions can be largely avoided by taking clarithromycin and zidovudine at 4-hour intervals. No such interaction has been observed in HIV-infected children taking clarithromycin infant suspension with zidovudine or dideoxynosine. Because clarithromycin can interfere with the absorption of zidovudine when they are taken simultaneously orally in adult patients, this interaction is unlikely to occur when clarithromycin is used by injection.

Phenytoin and valproic acid. There are data on interaction of CYP3A isoenzyme inhibitors (including clarithromycin) with drugs that are not metabolized by CYP3A isoenzyme (phenytoin and valproic acid). For these drugs when used concomitantly with clarithromycin, determination of their serum concentrations is recommended, since there have been reports of elevated concentrations.

Bi-directional drug interactions

Atazanavir. Clarithromycin and atazanavir are both substrates and inhibitors of the CYP3A isoenzyme. There is evidence of a bidirectional interaction between these drugs. Concomitant use of clarithromycin (500 mg twice daily) and atazanavir (400 mg once daily) may result in a twofold increase in clarithromycin exposure and a 70% decrease in 14-OH-clarithromycin exposure with a 28% increase in atazanavir AUC. Due to the wide therapeutic range of clarithromycin, no dose reduction is required in patients with normal renal function.

In patients with moderate renal impairment (creatinine Cl 30-60 ml/min), the dose of clarithromycin should be reduced by 50%. In patients with a creatinine Cl less than 30 ml/min, the clarithromycin dose should be reduced by 75% with an appropriate clarithromycin dosage form. Clarithromycin in doses greater than 1000 mg/day should not be used concomitantly with protease inhibitors.

BKK. Caution should be exercised when concomitant use of clarithromycin and BQCs that are metabolized by CYP3A4 isoenzyme (e.g. verapamil, amlodipine, diltiazem), as there is a risk of arterial hypotension. Concomitant use may increase plasma concentrations of clarithromycin and BKK. Arterial hypotension, bradyarrhythmia and lactoacidosis are possible with concomitant use of clarithromycin and verapamil.

Itraconazole. Clarithromycin and itraconazole are substrates and inhibitors of CYP3A isoenzyme, which determines a bidirectional interaction of the drugs. Clarithromycin may increase the plasma concentration of itraconazole, while itraconazole may increase the plasma concentration of clarithromycin. Patients taking itraconazole and clarithromycin concomitantly should be carefully examined for symptoms of increased or prolonged duration of pharmacological effects of these drugs.

Saquinavir. Clarithromycin and saquinavir are substrates and inhibitors of CYP3A isoenzyme, which determines a bidirectional interaction of the drugs. Concomitant use of clarithromycin (500 mg 2 times daily) and saquinavir (in soft gelatin capsules, 1200 mg 3 times daily) in 12 healthy volunteers caused an increase in plasma AUC and Cmax of saquinavir by 177 and 187%, respectively, compared with taking saquinavir alone. AUC and Cmax values of clarithromycin were approximately 40% higher than those of clarithromycin alone therapy. No dose adjustments are required when the two drugs are used concomitantly for a limited time in the doses/compositions listed above.

The results of drug interaction studies using saquinavir in soft gelatin capsules may not be consistent with the effects observed with saquinavir in hard gelatin capsules. The results of studies of drug interactions during therapy with saquinavir alone may not correspond to the effects observed during therapy with the saquinavir/ritonavir combination. The potential effects of ritonavir on clarithromycin should be considered when taking saquinavir concomitantly with ritonavir.

Special Instructions

Prolonged use of antibiotics can lead to the formation of colonies with increased numbers of insensitive bacteria and fungi. Appropriate therapy should be administered if superinfection occurs.

Hepatic dysfunction (increased plasma liver enzyme activity, hepatocellular and/or cholestatic hepatitis with or without jaundice) has been reported with clarithromycin.

Hepatic dysfunction can be severe, but is usually reversible. There have been cases of fatal liver failure, mostly related to the presence of serious comorbidities and/or concomitant use of other medications. In case of signs and symptoms of hepatitis, such as anorexia, jaundice, darkened urine, itching of the skin, abdominal pain on palpation, clarithromycin therapy should be stopped immediately.

In the presence of chronic liver disease, regular monitoring of serum liver enzyme activity is necessary.

When treated with almost all antibacterial agents, including clarithromycin, there have been described cases of pseudomembranous colitis, the severity of which may vary from mild to life-threatening. Antibacterials can change normal gut flora, which can lead to growth of Clostridium difficile.

Pseudomembranous colitis caused by Clostridium difficile should be suspected in all patients with diarrhea after antibiotic use. After a course of antibiotic therapy, careful medical follow-up of the patient is necessary. Cases of pseudomembranous colitis have been described 2 months after antibiotic use.

Long QT interval. A prolonged period of myocardial repolarization and the QT interval, increasing the risk of cardiac arrhythmias and pirouette arrhythmias, have been reported with macrolides, including clarithromycin. Clarithromycin use may increase the risk of ventricular arrhythmias (including pirouette arrhythmias), so clarithromycin should be used with caution:

– in patients with CHD, severe heart failure, impaired cardiac conduction, clinically significant bradycardia;

– in patients with water-electrolyte disorders, such as hypomagnesemia. Clarithromycin should not be administered to patients with hypokalemia;

– when concomitantly used with other drugs associated with prolongation of the QT interval (see “Interaction”).

The development of cross-resistance to clarithromycin and other antibiotics of the macrolide group, as well as to lincomycin and clindamycin is possible.

In view of the increasing resistance of Streptococcus pneumoniae to macrolides, it is important to perform sensitivity testing when prescribing clarithromycin to patients with community-acquired pneumonia. In hospital pneumonia, clarithromycin should be used in combination with appropriate antibiotics.

Mild to moderate skin and soft tissue infections are most commonly caused by Staphylococcus aureus and Streptococcus pyogenes. Both pathogens may be resistant to macrolides. Therefore, it is important to test for antibiotic sensitivity.

Macrolides can be used for infections caused by Corynebacterium minutissimum (erythrasma), acne vulgaris and rye, and in situations where penicillin cannot be used.

In case of acute hypersensitivity reactions such as anaphylactic reaction, Stevens-Johnson syndrome, toxic epidermal necrolysis and drug rash with eosinophilia and systemic symptoms (DRESS syndrome), clarithromycin should be stopped immediately and appropriate therapy started.

In case of concomitant use with warfarin or other indirect anticoagulants, the INR and PV should be monitored (see “Interaction”).

Impact on driving and operating ability. There are no data on the effect of clarithromycin on the ability to drive and operate machinery. The potential for dizziness, vertigo, confusion and disorientation that may occur with this drug should be considered.

Caution should be exercised when driving vehicles and engaging in other potentially hazardous activities requiring increased concentration and quick psychomotor reactions.

Synopsis

Fracture appearance: a rough mass of white or almost white color with a brown-yellow film coating.

Contraindications

Hypersensitivity to drug components and other macrolides;

Severe renal impairment (creatinine Cl less than 30 ml/min);

Concomitant administration of clarithromycin with the following drugs: astemizole, cisapride, pimozide, terfenadine (see “Interaction.

Concomitant administration of clarithromycin with ergot alkaloids, e.g. ergotamine, dihydroergotamine (see “Interactions”).

Concomitant administration of clarithromycin with oral midazolam (see “Interactions”).

Concomitant administration of clarithromycin with HMG-CoA reductase inhibitors (statins) that are largely metabolized by the CYP3A4 isoenzyme (lovastatin, simvastatin) due to an increased risk of myopathy, including rhabdomyolysis (see “Interaction”). “Interactions);

Concomitant use of clarithromycin with colchicine;

Concomitant use with ticagrelor or ranolazine;

history of ECG prolongation of the QT interval (congenital or documented QT interval prolongation), history of ventricular arrhythmia, or history of pirouette-type ventricular tachycardia;

Hypkalemia (risk of ECG QT interval prolongation);

Severe hepatic impairment accompanied by renal impairment;

Cholestatic jaundice/hepatitis with a history of clarithromycin use (see “Precautions. “

Porphyria;

Lactose intolerance, lactase deficiency, glucose-galactose malabsorption syndrome;

Breastfeeding period;

Above 18 years of age (with indications: tonsillitis, acute otitis media), under 12 years of age (for other indications).

With caution: moderate to severe renal impairment; moderate to severe hepatic impairment; concomitant administration of clarithromycin with benzodiazepines such as alprazolam, triazolam, midazolam for IV administration (see “Interactions”). Interaction); concomitant administration with drugs that are metabolized by CYP3A isoenzymes, e.g. carbamazepine, cilostazol, cyclosporine, disopyramide, methylprednisolone, omeprazole, indirect anticoagulants (e.g. warfarin), quinidine, rifabutin, sildenafil, tacrolimus, vinblastine (see “Interaction”). “Interaction”); concomitant administration with drugs that induce the CYP3A4 isoenzyme, e.g. rifampicin, phenytoin, carbamazepine, phenobarbital, St. John’s wort (see “Interaction”). “Interaction”); concomitant administration with BCCs that are metabolized by CYP3A4 isoenzymes (e.g. verapamil, amlodipine, diltiazem); concomitant administration with other ototoxic drugs, especially aminoglycosides; concomitant use with statins that do not depend on CYP3A4 isoenzyme metabolism (e.g. fluvastatin); patients with coronary heart disease (CHD), severe heart failure, hypomagnesemia, severe bradycardia (less than 50 bpm), and patients with cardiac insufficiency./min), as well as patients who simultaneously take antiarrhythmic drugs of class IA (quinidine, procainamide) and class III (dofetilide, amiodarone, sotalol); pregnancy.

Side effects

The World Health Organization (WHO) classification of the incidence of adverse effects is: very common – ≥1/10; common – ≥1/100 to < 1/10; infrequent – ≥1/1000 to < 1/100; rare – ≥1/10000 to < 1/1000; very rare – < 1/10000; frequency unknown – cannot be estimated based on available data. Within each group, adverse effects are presented in decreasing order of severity.

Allergic reactions: Frequent – skin rash; infrequent – anaphylactoid reaction1, hypersensitivity, bullous1 dermatitis, pruritus, urticaria, maculopapular rash3; frequency unknown – anaphylactic reaction, angioneurotic edema, Stevens-Johnson syndrome, toxic epidermal necrolysis, drug rash with eosinophilia and systemic symptomatology (DRESS syndrome).

Nervous system disorders: Frequent – headache, insomnia; infrequent – loss of consciousness1, dyskinesia1, dizziness, somnolence, tremor, restlessness, hyperexcitability3; frequency unknown – seizures, psychotic disorders, confusion, depersonalization, depression, disorientation, hallucinations, dream disorders (“nightmare” dreams), paresthesia, mania.

Skin disorders: often – intense sweating; frequency unknown – acne, hemorrhages.

Urinary system disorders: frequency unknown – renal failure, interstitial nephritis.

Metabolism and nutrition: infrequent – anorexia, decreased appetite.

Musculoskeletal system: infrequent – muscle spasm, musculoskeletal stiffness, myalgia; frequency unknown – rhabdomyolysis2.5, myopathy.

Digestive system disorders: frequent – diarrhea, vomiting, dyspepsia, nausea, abdominal pain; infrequent – esophagitis1, gastroesophageal reflux disease2, gastritis, proctalgia2, stomatitis, glossitis, bloating4, constipation, dry oral mucosa, belching, flatulence, cholestasis4, hepatitis including. including cholestatic or hepatocellular4; frequency unknown – acute pancreatitis, discoloration of tongue and teeth, liver failure, cholestatic jaundice.

Respiratory system: infrequent – bronchial asthma1, nasal bleeding2, pulmonary embolism1.

Senses: frequent – dysgeusia (perversion of taste); infrequent – vertigo, impaired hearing, tinnitus; frequency unknown – deafness, agueusia (loss of taste), parosmia, anosmia.

Particularly cardiac disorders: frequently – vasodilation1; infrequently – sudden cardiac arrest1, atrial fibrillation1, prolongation of QT interval in ECG, extrasystole1, atrial flutter; frequently unknown – ventricular tachycardia including “pirouette” type, ventricular fibrillation.

Laboratory measures: frequent – deviation of laboratory indicators of liver function; infrequent – increased concentration of creatinine1, increased concentration of urea1 in blood plasma, change in albumin/globulin ratio1, leukopenia, neutropenia4, eosinophilia4, thrombocythemia3, increased activity of AJIT, ACT, GGT4, ALF4, LDH4 in blood plasma; frequency unknown – agranulocytosis, thrombocytopenia, increased INR, prolongation of PV, color changes in urine, increased plasma bilirubin concentration.

Others: infrequent – malaise4, hyperthermia3, asthenia, chest pain4, chills4, increased fatigue4.

Infectious and parasitic diseases: infrequent – cellulitis1, candidiasis, gastroenteritis2, secondary infections3 (including vaginal); frequency unknown – pseudomembranous colitis, rye.

Patients with suppressed immunity

In patients with AIDS and other immunodeficiencies receiving clarithromycin at higher doses for long term treatment of mycobacterial infections, it is often difficult to distinguish adverse effects of the drug from symptoms of HIV infection or co-morbidity.

The most common adverse events in patients taking a daily dose of clarithromycin equal to 1000 mg were: nausea, vomiting, dysgeusia (perversion of taste), abdominal pain, diarrhea, skin rash, flatulence, headache, constipation, hearing disorders, and increased ACT and ALT activity in blood plasma. There have also been cases of adverse events with low frequency of occurrence, such as: dyspnea, insomnia, and dry oral mucosa.

In patients with suppressed immunity, laboratory values were evaluated by analyzing their significant deviations from the norm (sharp increase or decrease). Based on this criterion, in 2-3% of patients who received clarithromycin at a dose of 1000 mg daily, a significant increase in plasma ACT and ALT activity was recorded, as well as a decrease in leukocyte and platelet counts. A small number of patients also registered an increase in plasma residual urea nitrogen concentration.

1 These adverse reactions have been reported in clinical studies as well as in post-marketing use of clarithromycin in the form of lyophilisate for preparation of solution for infusion.

2 Reports of these adverse reactions have been received during clinical studies as well as post-marketing use of clarithromycin in the dosage form of film-coated sustained release tablets.

3 These adverse reactions have been reported in clinical studies as well as in post-marketing use of clarithromycin in the oral suspension powder form.

4 Reports of these adverse reactions have been received during clinical studies as well as post-marketing use of clarithromycin in the dosage form of film-coated tablets.

5 In some reports of rhabdomyolysis, clarithromycin has been taken concomitantly with other drugs known to be associated with rhabdomyolysis (statins, fibrates, colchicine or allopurinol).

Overdose

Symptoms: ingestion of a large dose of clarithromycin may cause symptoms of GI disorders. One patient with a history of bipolar disorder has described mental status changes, paranoid behavior, hypokalemia and hypoxemia after taking 8 g of clarithromycin.

Treatment: in case of overdose the unabsorbed drug should be removed from the gastrointestinal tract (gastric lavage, administration of activated charcoal, etc.) and symptomatic therapy should be carried out. Hemodialysis and peritoneal dialysis have no significant effect on serum concentrations of clarithromycin, as is the case with other macrolide drugs.

Pregnancy use

The safety of clarithromycin in pregnancy and during breastfeeding has not been established.

The use of clarithromycin in pregnancy (especially in the first trimester) is possible only if there is no alternative therapy and the potential benefit to the mother exceeds the potential risk to the fetus.

Clarithromycin is excreted with the breast milk. Breast-feeding should be discontinued if it is necessary during breast-feeding.

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