1. Name Of The Medicinal Product
SOLIAN 100
2. Qualitative And Quantitative Composition
Amisulpride 100 mg per tablet
For excipients, see 6.1.
3. Pharmaceutical Form
Tablet
White to off-white, round, flat-faced tablet engraved AMI 100 on one face and with a breakable bar on the other face.
4. Clinical Particulars
4.1 Therapeutic Indications
Solian is indicated for the treatment of acute and chronic schizophrenic disorders, in which positive symptoms (such as delusions, hallucinations, thought disorders) and/or negative symptoms (such as blunted affect, emotional and social withdrawal) are prominent, including patients characterised by predominant negative symptoms.
4.2 Posology And Method Of Administration
For acute psychotic episodes, oral doses between 400 mg/d and 800 mg/d are recommended. In individual cases, the daily dose may be increased up to 1200 mg/d. Doses above 1200 mg/d have not been extensively evaluated for safety and therefore should not be used. No specific titration is required when initiating the treatment with Solian. Doses should be adjusted according to individual response.
For patients with mixed positive and negative symptoms, doses should be adjusted to obtain optimal control of positive symptoms.
Maintenance treatment should be established individually with the minimally effective dose.
For patients characterised by predominant negative symptoms, oral doses between 50 mg/d and 300 mg/d are recommended. Doses should be adjusted individually.
Solian can be administered once daily at oral doses up to 300 mg, higher doses should be administered bid.
The minimum effective dose should be used.
Elderly: Solian should be used with particular caution because of a possible risk of hypotension or sedation.
Children: The efficacy and safety of amisulpiride from puberty to the age of 18 years have not been established. There are limited data available on the use of amisulpiride in adolescents in schizophrenia. Therefore, the use of amisulpiride from puberty to the age of 18 years is not recommended; in children up to puberty amisulpiride is contraindicated (see Section 4.3).
Renal insufficiency: Solian is eliminated by the renal route. In renal insufficiency, the dose should be reduced to half in patients with creatinine clearance (CRCL) between 30-60 ml/min and to a third in patients with CRCL between 10-30 ml/min.
As there is no experience in patients with severe renal impairment (CRCL < 10 ml/min) particular care is recommended in these patients (see Section 4.4).
Hepatic insufficiency: since the drug is weakly metabolised a dosage reduction should not be necessary.
4.3 Contraindications
Hypersensitivity to the active ingredient or to other ingredients of the medicinal product
Concomitant prolactin-dependent tumours e.g. pituitary gland prolactinomas or breast cancer
Phaeochromocytoma
Children before the onset of puberty
Lactation
Combination with levodopa (see Section 4.5)
4.4 Special Warnings And Precautions For Use
As with other neuroleptics, Neuroleptic Malignant Syndrome, characterized by hyperthermia, muscle rigidity, autonomic instability, altered consciousness and elevated CPK, may occur. In the event of hyperthermia, particularly with high daily doses, all antipsychotic drugs including Solian should be discontinued.
Hyperglycaemia has been reported in patients treated with some atypical antipsychotic agents, including amisulpride, therefore patients with an established diagnosis of diabetes mellitus or with risk factors for diabetes who are started on amisulpride, should get appropriate glycaemic monitoring.
Solian is eliminated by the renal route. In cases of renal insufficiency, the dose should be decreased or intermittent treatment could be considered (see Section 4.2).
Solian may lower the seizure threshold. Therefore patients with a history of epilepsy should be closely monitored during Solian therapy.
In elderly patients, Solian, like other neuroleptics, should be used with particular caution because of a possible risk of hypotension or sedation.
As with other antidopaminergic agents, caution should be also exercised when prescribing Solian to patients with Parkinson's disease since it may cause worsening of the disease. Solian should be used only if neuroleptic treatment cannot be avoided.
Acute withdrawal symptoms including nausea, vomiting and insomnia have very rarely been described after abrupt cessation of high doses of antipsychotic drugs. Recurrence of psychotic symptoms may also occur, and the emergence of involuntary movement disorders (such as akathisia, dystonia and dyskinesia) has been reported. Therefore, gradual withdrawal is advisable.
Prolongation of the QT interval
Caution should be exercised when amisulpride is prescribed in patients with known cardiovascular disease or family history of QT prolongation.
Concomitant antipsychotics should be avoided.
Stroke:
In randomized clinical trials versus placebo performed in a population of elderly patients with dementia and treated with certain atypical antipsychotic drugs, a 3-fold increase of the risk of cerebrovascular events has been observed. The mechanism of such risk increase is not known. An increase in the risk with other antipsychotic drugs, or other populations of patients cannot be excluded. Solian should be used with caution in patients with stroke risk factors.
Increased Mortality in Elderly people with Dementia:
Data from two large observational studies showed that elderly people with dementia who are treated with antipsychotics are at a small increased risk of death compared with those who are not treated. There are insufficient data to give a firm estimate of the precise magnitude of the risk and the cause of the increased risk is not known.
Solian is not licensed for the treatment of dementia-related behavioural disturbances.
Venous thromboembolism:
Cases of venous thromboembolism (VTE) have been reported with antipsychotic drugs. Since patients treated with antipsychotics often present with acquired risk factors for VTE, all possible risk factors for VTE should be identified before and during treatment with Solian and preventive measures undertaken.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
COMBINATIONS WHICH ARE CONTRAINDICATED
Levodopa : reciprocal antagonism of effects between levodopa and neuroleptics.
COMBINATIONS WHICH ARE NOT RECOMMENDED
Solian may enhance the central effects of alcohol.
COMBINATIONS TO BE TAKEN INTO ACCOUNT
CNS depressants including narcotics, anaesthetics, analgesics, sedative H1 antihistamines, barbiturates, benzodiazepines and other anxiolytic drugs, clonidine and derivatives
Antihypertensive drugs and other hypotensive medications
Caution is advised when prescribing amisulpride with medicines known to prolong the QT interval, e.g., class IA antiarrythmics (e.g., quinidine, disopyramide) and class III antiarrhythmics (e.g. amiodarone, sotalol), some antihistaminics, some other antipsychotics and antimalarials (e.g., mefloquine) (see Section 4.4).
4.6 Pregnancy And Lactation
Pregnancy
In animals, Solian did not show reproductive toxicity. A decrease in fertility linked to the pharmacological effects of the drug (prolactin mediated effect) was observed. No teratogenic effects of Solian were noted.
Very limited clinical data on exposed pregnancies are available. Therefore, the safety of Solian during human pregnancy has not been established.
Use of the drug is not recommended during pregnancy unless the benefits justify the potential risks. If amisulpride is used during pregnancy, neonates may show adverse effects of amisulpride and thus appropriate monitoring should be considered.
For women of childbearing potential, effective contraception should be fully discussed with the physician prior to treatment.
Neonates exposed to antipsychotics (including Solian) during the third trimester of pregnancy are at risk of adverse reactions including extrapyramidal and/or withdrawal symptoms that may vary in severity and duration following delivery. There have been reports of agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, or feeding disorder. Consequently, newborns should be monitored carefully.
Lactation
It is not known whether Solian is excreted in breast milk, breast-feeding is therefore contra-indicated.
4.7 Effects On Ability To Drive And Use Machines
Even used as recommended, Solian may cause somnolence so that the ability to drive vehicles or operate machinery can be impaired (see Section 4.8 Undesirable effects).
4.8 Undesirable Effects
Adverse effects have been ranked under headings of 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); frequency not known (cannot be estimated from the available data).
Clinical trials data
The following adverse effects have been observed in controlled clinical trials. It should be noted that in some instances it can be difficult to differentiate adverse events from symptoms of the underlying disease.
• Nervous system disorders:
Very common: Extrapyramidal symptoms may occur: tremor, rigidity, hypokinesia, hypersalivation, akathisia, dyskinesia. These symptoms are generally mild at optimal dosages and partially reversible without discontinuation of amisulpride upon administration of antiparkinsonian medication. The incidence of extrapyramidal symptoms which is dose related, remains very low in the treatment of patients with predominantly negative symptoms with doses of 50-300 mg/day.
Common: Acute dystonia (spasm torticollis, oculogyric crisis, trismus) may appear. This is reversible without discontinuation of amisulpride upon treatment with an antiparkinsonian agent. Somnolence.
Uncommon: Tardive dyskinesia characterized by rhythmic, involuntary movements primarily of the tongue and/or face have been reported, usually after long term administration. Antiparkinsonian medication is ineffective or may induce aggravation of the symptoms. Seizures.
• Psychiatric disorders:
Common: Insomnia, anxiety, agitation, orgasmic dysfunction
• Gastrointestinal disorders
Common: Constipation, nausea, vomiting, dry mouth
• Endocrine disorders:
Common: Amisulpride causes an increase in plasma prolactin levels which is reversible after drug discontinuation. This may result in galactorrhoea, amenorrhoea, gynaecomastia, breast pain, and erectile dysfunction.
• Metabolism and nutrition disorders
Uncommon: Hyperglycemia (see Section 4.4).
• Cardiovascular disorders
Common: Hypotension
Uncommon: Bradycardia
• Investigations:
Common: Weight gain
Uncommon: Elevations of hepatic enzymes, mainly transaminases
• Immune system disorders
Uncommon: Allergic reaction
Post Marketing data
In addition, cases of the following adverse reactions have been reported through spontaneous reporting only:
• Nervous system disorders:
Frequency not known: Neuroleptic Malignant Syndrome (see Section 4.4).
• Cardiac disorders:
Frequency not known: QT interval prolongation and ventricular arrhythmias such as torsade de pointes, ventricular tachycardia, which may result in ventricular fibrillation or cardiac arrest, sudden death (see Section 4.4).
• Vascular disorders:
Frequency not known: Cases of venous thromboembolism, including cases of pulmonary embolism and cases of deep vein thrombosis have been reported with antipsychotic drugs.
• Skin and subcutaneous tissue disorders:
Frequency not known: Angioedema, urticaria
• Pregnancy, puerperium and perinatal conditions:
Frequency not known: Drug withdrawal syndrome neonatal (see section 4.6)
4.9 Overdose
Experience with Solian in overdosage is limited. Exaggeration of the known pharmacological effects of the drug have been reported. These include drowsiness and sedation, coma, hypotension and extrapyramidal symptoms. Fatal outcomes have been reported mainly in combination with other psychotropic agents.
In cases of acute overdosage, the possibility of multiple drug intake should be considered.
Since Solian is weakly dialysed, hemodialysis is of no use to eliminate the drug.
There is no specific antidote to Solian.
Appropriate supportive measures should therefore be instituted with close supervision of vital functions including continuous cardiac monitoring due to the risk of prolongation of the QT interval until the patient recovers.
If severe extrapyramidal symptoms occur, anticholinergic agents should be administered.
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
Pharmacotherapeutic group: Antipsychotics, ATC code N05A L05
Amisulpride binds selectively with a high affinity to human dopaminergic D2/D3 receptor subtypes whereas it is devoid of affinity for D1, D4 and D5 receptor subtypes.
Unlike classical and atypical neuroleptics, amisulpride has no affinity for serotonin, 1 and cholinergic receptors. In addition, amisulpride does not bind to sigma sites.
In animal studies, at high doses, amisulpride blocks dopamine receptors located in the limbic structures in preference to those in the striatum.
At low doses it preferentially blocks pre-synaptic D2/D3 receptors, producing dopamine release responsible for its disinhibitory effects.
This pharmacological profile explains the clinical efficacy of Solian against both negative and positive symptoms of schizophrenia.
5.2 Pharmacokinetic Properties
In man, amisulpride shows two absorption peaks: one which is attained rapidly, one hour post-dose and a second between 3 and 4 hours after administration. Corresponding plasma concentrations are 39 ± 3 and 54 ± 4 ng/ml after a 50 mg dose.
The volume of distribution is 5.8 l/kg, plasma protein binding is low (16%) and no drug interactions are suspected.
Absolute bioavailability is 48%. Amisulpride is weakly metabolised: two inactive metabolites, accounting for approximately 4% of the dose, have been identified. There is no accumulation of amisulpride and its pharmacokinetics remain unchanged after the administration of repeated doses. The elimination half-life of amisulpride is approximately 12 hours after an oral dose.
Amisulpride is eliminated unchanged in the urine. Fifty percent of an intravenous dose is excreted via the urine, of which 90% is eliminated in the first 24 hours. Renal clearance is in the order of 20 l/h or 330 ml/min.
A carbohydrate rich meal (containing 68% fluids) significantly decreases the AUCs, Tmax and Cmax of amisulpride but no changes were seen after a high fat meal. However, the significance of these findings in routine clinical use is not known.
Hepatic insufficiency: since the drug is weakly metabolised a dosage reduction should not be necessary in patients with hepatic insufficiency.
Renal insufficiency: The elimination half-life is unchanged in patients with renal insufficiency while systemic clearance is reduced by a factor of 2.5 to 3. The AUC of amisulpride in mild renal failure increased two fold and almost tenfold in moderate renal failure (see chapter 4.2). Experience is however limited and there is no data with doses greater than 50 mg.
Amisulpride is very weakly dialysed.
Limited pharmacokinetic data in elderly subjects (> 65 years) show that a 10-30 % rise occurs in Cmax, T1/2 and AUC after a single oral dose of 50 mg. No data are available after repeat dosing.
5.3 Preclinical Safety Data
An overall review of the completed safety studies indicates that Solian is devoid of any general, organ-specific, teratogenic, mutagenic or carcinogenic risk. Changes observed in rats and dogs at doses below the maximum tolerated dose are either pharmacological effects or are devoid of major toxicological significance under these conditions. Compared with the maximum recommended dosages in man, maximum tolerated doses are 2 and 7 times greater in the rat (200 mg/kg/d) and dog (120 mg/kg/d) respectively in terms of AUC. No carcinogenic risk, relevant to man, was identified in the rat at up to 1.5 to 4.5 times the expected human AUC.
A mouse carcinogenicity study (120 mg/kg/d) and reproductive studies (160, 300 and 500 mg/kg/d respectively in rat, rabbit and mouse) were performed. The exposure of the animals to amisulpride during these latter studies was not evaluated.
6. Pharmaceutical Particulars
6.1 List Of Excipients
Sodium starch glycolate, lactose monohydrate, microcrystalline cellulose, hypromellose, magnesium stearate.
6.2 Incompatibilities
None known.
6.3 Shelf Life
3 years
6.4 Special Precautions For Storage
No special precautions.
6.5 Nature And Contents Of Container
PVC/aluminium foil blister packs containing 60 tablets
6.6 Special Precautions For Disposal And Other Handling
No special precautions
7. Marketing Authorisation Holder
Sanofi-aventis
One Onslow Street
Guildford
Surrey
GU1 4YS
UK
8. Marketing Authorisation Number(S)
PL 04425/0651
9. Date Of First Authorisation/Renewal Of The Authorisation
7 February 2009
10. Date Of Revision Of The Text
7 November 2011
LEGAL STATUS
POM
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