Summary of medicine characteristics - CO-AMOXICLAV 250/62.5 MG / 5 ML POWDER FOR ORAL SUSPENSION
SUMMARY OF PRODUCT CHARACTERISTICS
NAME OF THE MEDICINAL PRODUCT
Co-amoxiclav 250/62.5mg/5 ml Powder for Oral Suspension
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
2QUALITATIVE AND QUANTITATIVE COMPOSITION
5ml reconstituted suspension contains:
Amoxicillin trihydrate 287mg corresponding to 250mg amoxicillin
Potassium Clavulanate 74.4mg corresponding to 62.5mg clavulanicacid
Excipient with known effect:
5ml reconstituted suspension contains 8.5mg aspartame.
For excipients, see section 6.1.
3. PHARMACEUTICAL FORM
Powder for oral suspension.
Off-white powder or off-white suspension once reconstituted.
CLINICAL PARTICULARS
4.1
Therapeutic indications
Co-amoxiclav is indicated for the treatment of the following infections in adults and children (see sections 4.2, 4.4and5.1):
Acute bacterial sinusitis (adequately diagnosed)
Acute otitis media
Acute exacerbations of chronic bronchitis (adequately diagnosed)
Community acquired pneumonia
Cystitis
Pyelonephritis
Skin and soft tissue infections in particular cellulitis, animal bites, severe dental abscess with spreading cellulitis.
Bone and joint infections, in particular osteomyelitis.
Consideration should be given to official guidance on the appropriate use of antibacterial agents.
4.2 Posology and method of administration
Doses are expressed throughout in terms of amoxicillin/clavulanic acid content except when doses are stated in terms of an individual component.
The dose of Co-amoxiclav that is selected to treat an individual infection should take into account:
The expected pathogens and their likely susceptibility to antibacterial agents (see section4.4)
The severity and the site of the infection
The age, weight and renal function of the patient as shownbelow.
The use of alternative presentations of Co-amoxiclav (e.g. those that provide higher doses of amoxicillin and/or different ratios of amoxicillin to clavulanic acid) should be considered as necessary (see sections 4.4and5.1).
For adults and children D40 kg, this formulation of Co-amoxiclav provides a total daily dose of 1500mg amoxicillin/375 mg clavulanic acid, when administered as recommended below. For children <40 kg, this formulation of Co-amoxiclav provides a maximum daily dose of 2400mg amoxicillin/600 mg clavulanic acid, when administered as recommended below. If it is considered that a higher daily dose of amoxicillin is required, it is recommended that another preparation of Co-amoxiclav is selected in order to avoid administration of unnecessarily high daily doses of clavulanic acid (see sections 4.4and5.1).
The duration of therapy should be determined by the response of the patient. Some infections (e.g. osteomyelitis) require longer periods of treatment. Treatment should not be extended beyond 14days without review (see section 4.4regarding prolonged therapy).
Adults and children □ 40kg
One 500mg/125 mg dose taken three times a day.
Children <40 kg
20mg/5 mg/kg/day to 60mg/15 mg/kg/day given in three divideddoses.
Children may be treated with Co-amoxiclav tablets, suspensions or paediatric sachets. Children aged 6years and below should preferably be treated with Co-amoxiclav suspension or paediatric sachets.
No clinical data are available on doses of Co-amoxiclav 4:1 formulations higher than 40mg/10 mg/kg per day in children under 2years.
Elderly
No dose adjustment is considered necessary.
Renal impairment
Dose adjustments are based on the maximum recommended level of amoxicillin.
No adjustment in dose is required in patients with creatinine clearance (CrCl) greater than 30ml/min.
Adults and children □ 40kg____________________________________________________
Children <40 kg
| CrCl: 10–30 ml/min | 15mg/3.75mg/kg twice daily (maximum 500mg/125 mg twice daily). |
| CrCl <10 ml /min | 15mg/3.75mg/kg as a single daily dose (maximum 500mg/125mg). |
| Haemodialysis | 15mg/3.75mg/kg per day once daily. Prior to haemodialysis 15mg/3.75mg/kg. In order to restore circulating drug levels, 15mg/3.75mg per kg should be administered after haemodialysis. |
| CrCl: 10–30 ml/min | 500mg/125 mg twice daily |
| CrCl <10 ml /min | 500mg/125 mg once daily |
| Haemodialysis | 500mg/125 mg every 24hours, plus 500mg/125 mg during dialysis, to be repeated at the end of dialysis (as serum concentrations of both amoxicillin and clavulanic acid are decreased) |
Hepatic impairment
Dose with caution and monitor hepatic function at regular intervals (see sections 4.3and4.4).
Method of administration
Co-amoxiclav is for oral use.
Administer at the start of a meal to minimise potential gastrointestinal intolerance and optimise absorption of amoxicillin/clavulanicacid.
Space the doses evenly during the day, at least 4hoursapart.
Shake to loosen powder, add water as directed, invert andshake.
Shake the bottle before each dose (see section 6.6).
4.3 Contraindications
Hypersensitivity to the active substances, to any of the penicillins or to any of the excipients.
History of a severe immediate hypersensitivity reaction (e.g. anaphylaxis) to another beta-lactam agent (e.g. a cephalosporin, carbapenem or monobactam).
History of jaundice/hepatic impairment due to amoxicillin/clavulanic acid (see section4.8).
4.4 Special warnings and precautions for use
Before initiating therapy with amoxicillin/clavulanic acid, careful enquiry should be made concerning previous hypersensitivity reactions to penicillins, cephalosporins or other beta-lactam agents (see sections 4.3and4.8).
Serious and occasionally fatal hypersensitivity reactions (including anaphylactoid and severe cutaneous adverse reactions) have been reported in patients on penicillin therapy. These reactions are more likely to occur in individuals with a history of penicillin hypersensitivity and in atopic individuals. If an allergic reaction occurs, amoxicillin/clavulanic acid therapy must be discontinued and appropriate alternative therapy instituted.
In the case that an infection is proven to be due to an amoxicillin-susceptible organisms(s) then consideration should be given to switching from amoxicillin/clavulanic acid to amoxicillin in accordance with official guidance.
This presentation of Co-amoxiclav is not suitable for use when there is a high risk that the presumptive pathogens have reduced susceptibility or resistance to betalactam agents that is not mediated by beta-lactamases susceptible to inhibition by clavulanic acid. This presentation should not be used to treat penicillin-resistant S. pneumoniae.
Convulsions may occur in patients with impaired renal function or in those receiving high doses (see section4.8).
Amoxicillin/clavulanic acid should be avoided if infectious mononucleosis is suspected since the occurrence of a morbilliform rash has been associated with this condition following the use of amoxicillin.
Concomitant use of allopurinol during treatment with amoxicillin can increase the likelihood of allergic skin reactions.
Prolonged use may occasionally result in overgrowth of non-susceptible organisms.
The occurrence at the treatment initiation of a feverish generalised erythema associated with pustula may be a symptom of acute generalised exanthemous pustulosis (AGEP) (see Section 4.8). This reaction requires Co-amoxiclav discontinuation and contra-indicates any subsequent administration of amoxicillin.
Amoxicillin/clavulanic acid should be used with caution in patients with evidence of hepatic impairment (see section4.2).
Hepatic events have been reported predominantly in males and elderly patients and may be associated with prolonged treatment. These events have been very rarely reported in children. In all populations, signs and symptoms usually occur during or shortly after treatment but in some cases may not become apparent until several weeks after treatment has ceased. These are usually reversible. Hepatic events may be severe and, in extremely rare circ*mstances, deaths have been reported. These have almost always occurred in patients with serious underlying disease or taking concomitant medications known to have the potential for hepatic effects (see section4.8).
Antibiotic-associated colitis has been reported with nearly all antibacterial agents and may range in severity from mild to life threatening (see section 4.8). Therefore, it is important to consider this diagnosis in patients who present with diarrhoea during or subsequent to the administration of any antibiotics. Should antibiotic-associated colitis occur, amoxicillin/clavulanic acid should immediately be discontinued, a physician be consulted and an appropriate therapy initiated. Anti-peristaltic medicinal products are contra-indicated in this situation.
Periodic assessment of organ system functions, including renal, hepatic and haematopoietic function is advisable during prolonged therapy.
Prolongation of prothrombin time has been reported rarely in patients receiving amoxicillin/clavulanic acid. Appropriate monitoring should be undertaken when anticoagulants are prescribed concomitantly. Adjustments in the dose of oral anticoagulants may be necessary to maintain the desired level of anticoagulation (see section 4.5and4.8).
In patients with renal impairment, the dose should be adjusted according to the degree of impairment (see section4.2).
In patients with reduced urine output, crystalluria has been observed very rarely, predominantly with parenteral therapy. During the administration of high doses of amoxicillin, it is advisable to maintain adequate fluid intake and urinary output in order to reduce the possibility of amoxicillin crystalluria. In patients with bladder catheters, a regular check of patency should be maintained (see section4.9).
During treatment with amoxicillin, enzymatic glucose oxidase methods should be used whenever testing for the presence of glucose in urine because false positive results may occur with non-enzymatic methods.
The presence of Clavulanic acid in Co-amoxiclav may cause a non-specific binding of IgG and albumin by red cell membranes leading to a false positive Coombstest.
There have been reports of positive test results using the Bio-Rad Laboratories Platelia Aspergillus EIA test in patients receiving amoxicillin/clavulanic acid who were subsequently found to be free of Aspergillus infection. Cross-reactions with non-Aspergillus polysaccharides and polyfuranoses with Bio-Rad Laboratories Platelia Aspergillus EIA test have been reported. Therefore, positive test results in patients receiving amoxicillin/clavulanic acid should be interpreted cautiously and confirmed by other diagnostic methods.
Co-amoxiclav suspension contains aspartame, it should be administered with caution in patients with phenylketonuria. Aspartame is hydrolysed in the gastrointestinal tract when orally ingested. One of the major hydrolysis products is phenylalanine.
This medicine contains less than 1mmol sodium (23mg) per dose, that is to say essentially ‘sodium-free’.
4.5 Interaction with other medicinal products and other forms of interaction
Oral anticoagulants
Oral anticoagulants and penicillin antibiotics have been widely used in practice without reports of interaction. However, in the literature there are cases of increased international normalised ratio in patients maintained on acenocoumarol or warfarin and prescribed a course of amoxicillin. If co-administration is necessary, the prothrombin time or international normalised ratio should be carefully monitored with the addition or withdrawal of amoxicillin. Moreover, adjustments in the dose of oral anticoagulants may be necessary (see sections 4.4and4.8).
Methotrexate
Penicillins may reduce the excretion of methotrexate causing a potential increase in toxicity.
Probenecid
Concomitant use of probenecid is not recommended. Probenecid decreases the renal tubular secretion of amoxicillin. Concomitant use of probenecid may result in increased and prolonged blood levels of amoxicillin but not of clavulanicacid.
Mycophenolate mofetil
In patients receiving mycophenolate mofetil, reduction in pre-dose concentration of the active metabolite mycophenolic acid of approximately 50% has been reported following commencement of oral amoxicillin plus clavulanic acid. The change in predose level may not accurately represent changes in overall MPA exposure.
4.6 Pregnancy and lactation
Pregnancy
Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, parturition or postnatal development (see section 5.3). Limited data on the use of amoxicillin/clavulanic acid during pregnancy in humans do not indicate an increased risk of congenital malformations. In a single study in women with preterm, premature rupture of the foetal membrane it was reported that prophylactic treatment with amoxicillin/clavulanic acid may be associated with an increased risk of necrotising enterocolitis in neonates. Use should be avoided during pregnancy, unless considered essential by the physician.
Lactation
Both substances are excreted into breast milk (nothing is known of the effects of clavulanic acid on the breast-fed infant). Consequently, diarrhoea and fungus infection of the mucous membranes are possible in the breast-fed infant, so that breast-feeding might have to be discontinued. Amoxicillin/clavulanic acid should only be used during breast-feeding after benefit/risk assessment by the physician in charge.
4.7 Effects on ability to drive and use machines
No studies on the effects on the ability to drive and use machines have been performed. However, undesirable effects may occur (e.g. allergic reactions, dizziness, convulsions), which may influence the ability to drive and use machines (see section4.8).
4.8 Undesirable effects
The most commonly reported adverse drug reactions (ADRs) are diarrhoea, nausea and vomiting.
The ADRs derived from clinical studies and post-marketing surveillance with Co-amoxiclav, sorted by MedDRA System Organ Class are listedbelow.
The following terminologies have been used in order to classify the occurrence of undesirable effects.
Very common (□ 1/10)
Common (□ 1/100 to <1/10)
Uncommon (□ 1/1,000to <1/100)
Rare (□ 1/10,000to <1/1,000)
Very rare (<1/10,000)
Not known (cannot be estimated from the available data)
| Infections and infestations | |
| Mucocutaneous candidosis | Common |
| Overgrowth of non-susceptible organisms | Not known |
| Blood and lymphatic system disorders | |
| Reversible leucopenia (including neutropenia) | Rare |
| Thrombocytop enia | Rare |
| Reversible agranulocytosis | Not known |
| Haemolytic anaemia | Not known |
| Prolongation of bleeding time and prothrombin time1 | Not known |
| Immune system disorders10 | |
| Angioneurotic oedema | Not known |
| Anaphylaxis | Not known |
| Serum sickness-like syndrome | Not known |
| Hypersensitivity vasculitis | Not known |
| Nervous system disorders | |
| Dizziness | Uncommon |
| Headache | Uncommon |
| Reversible hyperactivity | Not known |
| 2 2 Convulsions | Not known |
| Aseptic meningitis | Not known |
| Gastrointestinal disorders | |
| Diarrhoea | Common |
| Nausea3 | Common |
| Vomiting | Common |
| Indigestion | Uncommon |
| Antibiotic-associated colitis4 | Not known |
| Black hairy tongue | Not known |
| Tooth discolouration11 | Not known |
| Hepatobiliary disorders | |
| Rises in AST and/or ALT5 | Uncommon |
| Hepatitis6 | Not known |
| Cholestatic jaundice6 | Not known |
| rii ♦ il. 7 !♦ i7 Skin and subcutaneous tissue disorders | |
| Skin rash | Uncommon |
| Pruritus | Uncommon |
| Urticaria | Uncommon |
| Erythema multiforme | Rare |
| Stevens-Johnson syndrome | Not known |
| Toxic epidermal necrolysis | Not known |
| Bullous exfoliative-dermatitis | Not known |
| Acute generalised exanthemous pustulosis (AGEP)9 | Not known |
| Renal and urinary disorders | |
| Interstitial nephritis | Not known |
| 8 ,11 ‘8 Crystalluria | Not known |
| 1See section 4.4 2See section 4.4 3Nausea is more often associated with higher oral doses. If gastrointestinal reactions are evident, they may be reduced by taking Co-amoxiclav at the start of ameal. 4Including pseudomembranous colitis and haemorrhagic colitis (see section4.4) 5Amoderate rise in AST and/or ALT has been noted in patients treated with beta-lactam class antibiotics, but the significance of these findings is unknown. 6These events have been noted with other penicillins and cephalosporins (see section4.4). 7If any hypersensitivity dermatitis reaction occurs, treatment should be discontinued (see section4.4). 8See section 4.9 9See section 4.4 10See sections 4.3and 4.4 11Superficial tooth discolouration has been reported very rarely in children. | |
Good oral hygiene may help to prevent tooth discolouration as it can usually be removed by brushing.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme (www.mhra.gov.uk/yellowcard) or search for MHRA Yellow Card in the Google Play or Apple AppStore.
4.9 Overdose
Symptoms and signs of overdose
Gastrointestinal symptoms and disturbance of the fluid and electrolyte balances may be evident. Amoxicillin crystalluria, in some cases leading to renal failure, has been observed (see section4.4).
Convulsions may occur in patients with impaired renal function or in those receiving highdoses.
Amoxicillin has been reported to precipitate in bladder catheters, predominantly after intravenous administration of large doses. Aregular check of patency should be maintained (see section4.4).
Treatment of intoxication
Gastrointestinal symptoms may be treated symptomatically, with attention to the water/electrolyte balance.
Amoxicillin/clavulanic acid can be removed from the circulation by haemodialysis.
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Combinations of penicillins, incl. beta-lactamase inhibitors; ATC code: J01CR02.
Mode of action
Amoxicillin is a semisynthetic penicillin (beta-lactam antibiotic) that inhibits one or more enzymes (often referred to as penicillin-binding proteins, PBPs) in the biosynthetic pathway of bacterial peptidoglycan, which is an integral structural component of the bacterial cell wall. Inhibition of peptidoglycan synthesis leads to weakening of the cell wall, which is usually followed by cell lysis anddeath.
Amoxicillin is susceptible to degradation by beta-lactamases produced by resistant bacteria and therefore the spectrum of activity of amoxicillin alone does not include organisms which produce these enzymes.
Clavulanic acid is a beta-lactam structurally related to penicillins. It inactivates some beta-lactamase enzymes thereby preventing inactivation of amoxicillin. Clavulanic acid alone does not exert a clinically useful antibacterial effect.
PK/PD relationship
The time above the minimum inhibitory concentration (T>MIC) is considered to be the major determinant of efficacy for amoxicillin.
Mechanisms of resistance
The two main mechanisms of resistance to amoxicillin/clavulanic acidare:
Inactivation by those bacterial beta-lactamases that are not themselves inhibited by clavulanic acid, including class B, C andD.
Alteration of PBPs, which reduce the affinity of the antibacterial agent for the target.
Impermeability of bacteria or efflux pump mechanisms may cause or contribute to bacterial resistance, particularly in Gram-negative bacteria.
Breakpoints
MIC breakpoints for amoxicillin/clavulanic acid are those of the European Committee on Antimicrobial Susceptibility Testing (EUCAST)
| Organism | Susceptibility Breakpoints (|ag /ml) | ||
| Susceptible | Intermediate | Resistant | |
| Haemophilus influenzae1 | < 1 | – | > 1 |
| Moraxella catarrhalis1 | < 1 | – | > 1 |
| Staphylococcus aureus 2 | < 2 | – | > 2 |
| Coagulase-negative staphylococci 2 | < 0.25 | > 0.25 | |
| Enterococcus1 | < 4 | 8 | > 8 |
| Streptococcus A, B, C, G 5 | < 0.25 | – | > 0.25 |
| Streptococcus pneumoniae3 | < 0.5 | 1–2 | > 2 |
| Enterobacteriaceae1,4 | – | – | > 8 |
| Gram-negative Anaerobes1 | < 4 | 8 | > 8 |
| Gram-positive Anaerobes1 | < 4 | 8 | > 8 |
| Non-species related breakpoints1 | < 2 | 4–8 | > 8 |
1The reported values are for Amoxicillin concentrations. For susceptibility testing purposes, the concentration of Clavulanic acid is fixed at 2mg/l.
2The reported values are Oxacillin concentrations.
3Breakpoint values in the table are based on Ampicillin breakpoints.
4The resistant breakpoint of R>8 mg/l ensures that all isolates with resistance mechanisms are reported resistant.
5Breakpoint values in the table are based on Benzylpenicillin breakpoints.
The prevalence of resistance may vary geographically and with time for selected species, and local information on resistance is desirable, particularly when treating severe infections. As necessary, expert advice should be sought when the local prevalence of resistance is such that the utility of the agent in at least some types of infections is questionable.
Commonly susceptible species
Aerobic Gram-positive micro-organisms
Enterococcus faecalis
Gardnerella vagin*lis
Staphylococcus aureus (methicillin-susceptible)£
Coagulase-negative staphylococci (methicillin-susceptible)
Streptococcus agalactiae
Streptococcus pneumoniae1
Streptococcus pyogenes and other beta-haemolytic streptococci
Streptococcus viridans group
Aerobic Gram-negative micro-organisms
Capnocytophaga spp.
Eikenella corrodens
Haemophilus influenzae2
Moraxella catarrhalis
Pasteurella multocida
Anaerobic micro-organisms
Bacteroides fragilis
Fusobacterium nucleatum
Prevotella spp.
Species for which acquired resistance may be a problem
Aerobic Gram-positive micro-organisms
Enterococcus faecium $
Aerobic Gram-negative micro-organisms
Escherichia coli
Klebsiella oxytoca
Klebsiella pneumoniae
Proteus mirabilis
Proteus vulgaris
Inherently resistant organisms
Aerobic Gram-negative micro-organisms
Acinetobacter sp.
Citrobacter freundii
Enterobacter sp.
Legionella pneumophila
Morganella morganii
Providencia spp.
Pseudomonas sp.
Serratia sp.
Stenotrophom*onas maltophilia
Other micro-organisms
Chlamydophila pneumoniae
Chlamydophila psittaci
Coxiella burnetti
Mycoplasma pneumoniae
$ Natural intermediate susceptibility in the absence of acquired mechanism of resistance.
£All methicillin-resistant staphylococci are resistant to amoxicillin/clavulanicacid
1Streptococcus pneumoniae that are resistant to penicillin should not be treated with this presentation of amoxicillin/clavulanic acid (see sections 4.2and4.4).
2Strains with decreased susceptibility have been reported in some countries in the EU with a frequency higher than10%.
5.2 Pharmaco*kinetic properties
Absorption
Amoxicillin and clavulanic acid, are fully dissociated in aqueous solution at physiological pH. Both components are rapidly and well absorbed by the oral route of administration. Absorption of amoxicillin/clavulanic acid is optimised when taken at the start of a meal. Following oral administration, amoxicillin and clavulanic acid are approximately 70% bioavailable. The plasma profiles of both components are similar and the time to peak plasma concentration (Tmax) in each case is approximately onehour.
The pharmaco*kinetic results for a study, in which amoxicillin/clavulanic acid (500mg/125 mg tablets three times daily) was administered in the fasting state to groups of healthy volunteers are presentedbelow.
| Mean (+/- SD) pharmaco*kinetic parameters | |||||
| Active substance(s) administered | Dose | Cmax | Tmax * | AUC (024h) | T 1/2 |
| (mg) | (pg/ml) | (h) | ((pg.h/ml) | (h) | |
| Amoxicillin | |||||
| AMX/CA | 500 | 7.19 | 1.5 | 53.5 | 1.15 |
| 500/125 mg | +/- | (1.0– | +/- 8.87 | +/- | |
| 2.26 | 2.5) | 0.20 | |||
Clavulanic acid
| AMX/CA | 125 | 2.40 | 1.5 | 15.72 | 0.98 |
| 500mg/125 | +/- | (1.0– | +/- 3.86 | +/- | |
| mg | 0.83 | 2.0) | 0.12 |
AMX– amoxicillin, CA– clavulanic acid * Median (range)
Amoxicillin and clavulanic acid serum concentrations achieved with amoxicillin/clavulanic acid are similar to those produced by the oral administration of equivalent doses of amoxicillin or clavulanic acidalone.
Distribution
About 25% of total plasma clavulanic acid and 18% of total plasma amoxicillin is bound to protein. The apparent volume of distribution is around 0.3–0.4l/kg for amoxicillin and around 0.2l/kg for clavulanicacid.
Following intravenous administration, both amoxicillin and clavulanic acid have been found in gall bladder, abdominal tissue, skin, fat, muscle tissues, synovial and peritoneal fluids, bile and pus. Amoxicillin does not adequately distribute into the cerebrospinalfluid.
From animal studies there is no evidence for significant tissue retention of drug-derived material for either component. Amoxicillin, like most penicillins, can be detected in breast milk. Trace quantities of clavulanic acid can also be detected in breast milk (see section4.6).
Both amoxicillin and clavulanic acid have been shown to cross the placental barrier (see section4.6).
Biotransformation
Amoxicillin is partly excreted in the urine as the inactive penicilloic acid in quantities equivalent to up to 10to 25% of the initial dose. Clavulanic acid is extensively metabolized in man and eliminated in urine and faeces and as carbon dioxide in expiredair.
Elimination
The major route of elimination for amoxicillin is via the kidney, whereas for clavulanic acid it is by both renal and non-renal mechanisms.
Amoxicillin/clavulanic acid has a mean elimination half-life of approximately one hour and a mean total clearance of approximately 25l/h in healthy subjects. Approximately 60to 70% of the amoxicillin and approximately 40to 65% of the clavulanic acid are excreted unchanged in urine during the first 6h after administration of single Co-amoxiclav 250mg/125 mg or 500mg/125 mg tablets. Various studies have found the urinary excretion to be 50–85% for amoxicillin and between 27–60% for clavulanic acid over a 24hour period. In the case of clavulanic acid, the largest amount of drug is excreted during the first 2hours after administration.
Concomitant use of probenecid delays amoxicillin excretion but does not delay renal excretion of clavulanic acid (see section4.5).
Age
The elimination half-life of amoxicillin is similar for children aged around 3months to 2years and older children and adults. For very young children (including preterm newborns) in the first week of life the interval of administration should not exceed twice daily administration due to immaturity of the renal pathway of elimination. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.
Gender
Following oral administration of amoxicillin/clavulanic acid to healthy males and female subjects, gender has no significant impact on the pharmaco*kinetics of either amoxicillin or clavulanicacid.
Renal impairment
The total serum clearance of amoxicillin/clavulanic acid decreases proportionately with decreasing renal function. The reduction in drug clearance is more pronounced for amoxicillin than for clavulanic acid, as a higher proportion of amoxicillin is excreted via the renal route. Doses in renal impairment must therefore prevent undue accumulation of amoxicillin while maintaining adequate levels of clavulanic acid (see section4.2).
Hepatic impairment
Hepatically impaired patients should be dosed with caution and hepatic function monitored at regular intervals.
5.3 Preclinical safety data
5.3Preclinical safety data
Nonclinical data reveal no special hazard for humans based on studies of safety pharmacology, genotoxicity and toxicity to reproduction.
Repeat dose toxicity studies performed in dogs with amoxicillin/clavulanic acid demonstrate gastric irritancy and vomiting, and discoloured tongue.
Carcinogenicity studies have not been conducted with Co-amoxiclav or its components.
6. PHARMACEUTICAL PARTICULARS
6.1. List of excipients
Citric acid anhydrous, trisodium citrate anhydrous, aspartame, talc, guar galactomannan, colloidal silicon dioxide, flavourings (lemon, peach-apricot and orange (containing essence of bergamot)).
6.2. Incompatibilities
Not applicable
6.3. Shelf life
Powder for Oral suspension: 36months
Oral Suspension: 7days
6.4. Special precautions for storage
Powder for Oral suspension: Do not store above 25°C. Keep the container tightly closed. Store in the original container.
Oral Suspension: Store at 2°C– 8°C. Do not freeze. Keep the container tightly closed.
6.5. Nature and contents of container
Amber glass bottle with child resistant closure and measuringspoon.
The powder in each bottle reconstitutes to form 100ml of oral suspension.
6.6. Instruction for use and handling (, and disposal)
Preparation of the oral suspension: Shake well before reconstitution. Add 90ml of water to the powder, 100ml of ready to use suspension is obtained.
6.6 Special precautions for disposal and other handling
6.6Special precautions for disposal and other handling
Preparation of the oral suspension: Shake well before reconstitution. Add 90ml of water to the powder, 100ml of ready to use suspension is obtained.
Check the cap seal is intact before using.
7 MARKETING AUTHORISATION HOLDER
Sandoz Limited
Park View, Riverside Way
Watchmoor Park
Camberley, Surrey
GU15 3YL
United Kingdom
8.MARKETING AUTHORISATION NUMBER
PL 04416/0515
9.DATE OF FIRST AUTHORISATION/RENEWAL OF THE
AUTHORISATION
25November 2003
