Amisulpride

Amisulpride 100mg/ml Sugar Free Oral Solution

The active substance is amisulpride.

Each ml of oral solution contains 100mg of amisulpride.

Excipients with known effect:

Each ml of oral solution contains 1.2mg methyl parahydroxybenzoate (E218).

For the full list of excipients, see section 6.1.

Oral Solution

A clear, pale yellow colour solution with caramel odour.

Amisulpride is indicated for the treatment of schizophrenic disorders.

As a general recommendation; Amisulpride can be administered once a day at oral doses up to 400 mg, higher dose should be split into two separate doses

For acute psychotic episodes: Oral doses between 4 ml/day (400 mg/day) and 8 ml/day (800 mg/day) are recommended. In individual cases, the daily dose may be increased up to 12 ml/day (1200 mg/day). Doses above 12 ml/day (1200 mg/day) have not been extensively evaluated for safety and therefore should not be used. No specific titration is required when initiating the treatment with Amisulpride. Doses should be adjusted according to individual response.

Maintenance treatment should be established individually with the minimally effective dose.

For patients characterised by predominant negative symptoms: Oral doses between 0.5 ml/day (50 mg/day) and 3 ml/day (300 mg/day) are recommended. Doses should be adjusted individually.

The minimum effective dose should be used.

Elderly: The safety of amisulpride has been examined in a limited number of elderly patients. Amisulpride should be used with particular caution because of a possible risk of hypotension and sedation. Reduction in dosage may also be required because of renal insufficiency.

Children: The efficacy and safety of amisulpride from puberty to the age of 18 years have not been established. There are limited data available on the use of amisulpride in adolescents in schizophrenia. Therefore, the use of amisulpride from puberty to the age of 18 years is not recommended; in children up to puberty amisulpride is contraindicated, as its safety has not yet been established (see section 4.3).

Renal insufficiency: Amisulpride is eliminated by the renal route. In renal insufficiency, the dose should be reduced to half in patients with creatinine clearance (CR_CL) between 30-60 ml/min and to a third in patients with CR_CL between 10-30 ml/min. As there is no experience in patients with severe renal impairment (CR_CL < 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.

Method of administration

For oral use only.

The oral solution should be drunk with a liquid, which does not contain alcohol.

• Hypersensitivity to the active ingredient or to other ingredients of the medicinal product listed in section 6.1.

• Concomitant prolactin-dependent tumours (e.g. pituitary gland prolactinomas or breast cancer) (see section 4.4 and section 4.8)

• Phaeochromocytoma

• Children under 15

• Combination with

Neuroleptic Malignant Syndrome:

As with other neuroleptics, Neuroleptic Malignant Syndrome, a potentially fatal complication, 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 Amisulpride should be discontinued.

Hyperglycaemia:

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.

Renal insufficiency:

Amisulpride 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).

Seizure:

Amisulpride may lower the seizure threshold. Therefore patients with a history of epilepsy should be closely monitored during Amisulpride therapy.

Elderly patients:

In elderly patients, Amisulpride, like other neuroleptics, should be used with particular caution because of a possible risk of hypotension or sedation. Reduction in dosage may also be required because of renal insufficiency.

Parkinson's disease:

As with other antidopaminergic agents, caution should be also exercised when prescribing Amisulpride to patients with Parkinson's disease since it may cause worsening of the disease. Amisulpride should be used only if neuroleptic treatment cannot be avoided.

Withdrawal symptom:

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 of amisulpride 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 and concomitant use with neuroleptics should be avoided.

This effect, known to potentiate the risk of occurrence of serious ventricular rhythm disorders, in particular with torsade de point type, is increased by the existence of bradychardia, hypokalemia with long congenital QT (combination with a drug that increases the QTc interval) (see section 4.8)

It is therefore advisable, when the clinical situation allows, to make sure before any administration of the absence of factors that may favor the occurrence of this rhythm disorder:

• Bradycardia less than 55 beats per minute,

• hypokalemia,

• congenital prolongation of the QT interval,

• treatment in progress with a medicinal product liable to cause marked bradycardia (<55 beats per minute), hypokalemia, slowing of the intracardiac conduction, lengthening of the QTc interval (see sections 4.3 and 4.5).

It is recommended to perform an ECG in the initial assessment of patients to be treated long term with a neuroleptic

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. Amisulpride should be used with caution in patients with stroke risk factors.

Elderly patients with dementia:

Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death in clinical trials with atypical antipsychotics were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality.

The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear.

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 Amisulpride and preventive measures undertaken.

Breast cancer:

Amisulpride may increase prolactin levels. Therefore, caution should be exercised and patients with a history or a family history of breast cancer should be closely monitored during Amisulpride therapy.

Benign pituitary tumour:

Amisulpride may increase prolactin levels. Cases of benign pituitary tumours such as prolactinoma have been observed during amisulpride therapy (see section 4.8). In case of very high levels of prolactin or clinical signs of pituitary tumour (such as visual field defect and headache), pituitary imaging should be performed. If the diagnosis of pituitary tumour is confirmed, the treatment with amisulpride must be stopped (see section 4.3).

Hepatotoxicity:

Severe liver toxicity has been reported with the use of amisulpride. Patients should be informed of the need to report signs such as asthenia, anorexia, nausea, vomiting, abdominal pain or jaundice immediately to a doctor. Investigations including clinical examination and biological assessment of liver function should be undertaken immediately (see section 4.8)

Blood and Lymphatic system disorders:

Leukopenia, neutropenia and agranulocytosis have been reported with antipsychotics, including Amisulpride. Unexplained infections or fever may be evidence of blood dyscrasia (see section 4.8), and requires immediate haematological investigation.

Other:

Amisulpride is not recommended in combination with alcohol, dopaminergic antiparkinsonians, antiparasitics likely to give torsades de pointes, methadone, levodopa and other neuroleptics and other medicines likely to give torsades de pointes, sodium oxybate and hydroxychloroquine (see section 4.5).

Excipients warnings

This product contains methyl parahydroxybenzoate (E218), which may cause allergic reactions (possibly delayed).

Sedative drugs

It must be taken into account that many drugs or substances can add their depressant effects to the central nervous system and help to decrease alertness. These are morphine derivatives (analgesics, cough suppressants and substitution treatments), neuroleptics, barbiturates, benzodiazepine, anxiolytics other than benzodiazepines (for example, meprobamate), hypnotics, sedative antidepressants (amitriptyline, doxepin, mianserin, mirtazapine, trimipramine), sedative H1 antihistamines, central antihypertensives, baclofen and thalidomide.

Drugs that may cause torsades de pointes

This severe heart rhythm disorder can be caused by a number of medications including antiarrhythmics and medicines which induce Hypokalaemia (see hypokalaemia drugs). Hypokalaemia is a favouring factor of Torsadas de pointes as are bradycardia inducing drugs (see bradycardia causing drugs) or a pre-existing lengthening of the QT interval, congenital or acquired. The drugs causing the side effect include class Ia and III antiarrhythmics, some neuroleptics. Other molecules that do not belong to these classes are also involved. For dolasetron, erythromycin, spiramycin and vincamine, only the form administered intravenously are affected by this interaction.

The use of a drug which may cause Torsades de pointes with other drugs which may cause Torsades de pointes is generally contra indicated. However, some of them, due to their unavoidable nature, are an exception to the rule, being only not recommended with other drugs which may cause Torsade de points. These are methadone, hydroxychloroquine, antiparasitics (chloroquine, halofantrine, lumefantrine, pentamidine) and neuroleptics. However, citalopram, escitalopram, domperidone, hydroxyzine and piperaquine are contraindicated with all drugs which may cause Torsades de pointes

Contraindicated combinations

• Dopaminergics other than parkinson's (cabergoline, quinagolide) mutual antagonism of dopamine agonist and neuroleptics.

• Combination with citalopram, escitalopram, domperidone, hydroxyzine, piperaquine

Increased risk of ventricular rhythm disorders, especially torsade de pointes.

Combinations not recommended

• Antiparasitics likely to give torsades de pointes (chloroquine, halofantrine, lumefantrine, pentamidine)

Increased risk of ventricular rhythm disturbances, especially torsades de pointes.

If possible, stop one of the two treatments.

If the combination cannot be avoided, prior control of the QT and monitored ECG monitoring.

• Dopaminergic anti-Parkinson drugs (amantadine, apomorphine, bromocriptine, entacapone, lisuride, pergolide, piribedil, pramiprexole, rasagiline, ropinirole, rotigotine, selegiline, tolcapone)

Reciprocal antagonism of dopaminergic and neuroleptics.

The dopaminergic can cause or worsen psychotic disorders. If treatment with neuroleptics is necessary in the parkinsonian patient treated with dopaminergics, the latter must be gradually reduced until stopping (their sudden cessation exposes them to a risk of "neuroleptic malignant syndrome").

• Other drugs likely to give torsades de pointes: antiarrhythmic drugs class Ia (quinidine, hydroquinidine, disopyramide) and class III (amiodarone, dronedarone, sotalol, dofetilide, ibutilide), and other drugs such as arsenieux, diphémanil, dolasetron IV, erythromycin IV, levofloxacin, mequitazine, mizolastine, prucalopride, vincamine IV, moxifloxacin, spiramycin IV, toremifene, vandetanib

Increased risk of ventricular rhythm disturbances, especially torsades de pointes.

• Other neuroleptics likely to give torsades de pointes (chlorpromazine, cyamemazine, droperidol, flupenthixol, fluphenazine, haloperidol, levomepromazine, pimozide, pipamperone, pipotiazine, sulpiride, sultopride, tiapride, zuclopenthixol)

Increased risk of ventricular rhythm disturbances, especially torsades de pointes.

• Alcohol (drink or excipient)

Increase by alcohol of the sedative effect of these substances.

Impaired alertness can make driving and using machines dangerous.

Avoid taking alcoholic beverages and drugs containing alcohol.

• Levodopa

Reciprocal antagonism of levodopa and neuroleptics.

In the Parkinson's patient, use effective minimum doses of each of the two drugs.

• Methadone

Increased risk of ventricular rhythm disturbances, especially torsades de pointes.

• Sodium oxybate

Increase in central depression. Impaired alertness can make driving and using machines dangerous.

• Hydroxychloroquine

Increased risk of ventricular rhythm disturbances, especially torsade de pointes.

Combination subject to precautions for use

• Anagrelide

Increased risk of ventricular rhythm disturbances, especially torsades de pointes.

Clinical and electrocardiographic monitoring during the association.

• Azithromycin, ciprofloxacin, clarithromycin, levofloxacin, norfloxacin, roxithromycin

Increased risk of ventricular rhythm disturbances, especially torsades de pointes.

Clinical and electrocardiographic monitoring during the association.

• Beta blockers in heart failure (bisoprolol, carvedilol, metoprolol, nebivolol)

Increased risk of ventricular rhythm disturbances, especially torsades de pointes.

In addition, vasodilator effect and risk of hypotension, especially orthostatic (additive effect).

Clinical monitoring and electrocardiograph.

• Bradycardisants (in particular class Ia antiarrhythmics, beta-blockers, certain class III antiarrhythmics, certain calcium antagonists, digitalis, pilocarpine, anticholinesterases)

Increased risk of ventricular rhythm disturbances, especially torsades de pointes.

Clinical and electrocardiographic monitoring.

• Hypokalemic drugs (hypokalemic diuretics, alone or in combination, stimulant laxatives, glucocorticoids, tetracosactide and amphotericin B IV)

Increased risk of ventricular rhythm disturbances, especially torsades de pointes.

Correct any hypokalemia before administering the product and carry out clinical, electrolytic and electrocardiographic monitoring.

• Lithium

Risk of developing neuropsychic signs suggestive of a neuroleptic malignant syndrome or lithium intoxication. Regular clinical and biological monitoring, especially at the start of association.

• Ondansetron

Increased risk of ventricular rhythm disturbances, especially torsades de pointes.

Clinical and electrocardiographic monitoring during the association.

Combination to take into account

• Other sedative drugs

Increase in central depression.

Impaired alertness can make driving and using machines dangerous.

• Orlistat

Risk of therapeutic failure in case of concomitant treatment with orlistat

Pregnancy

There are limited data from the use of amisulpride in pregnant women. The safety of the use of amisulpride during pregnancy has not been established. Amisulpride crosses the placenta. Studies in animals have shown toxicity to reproductive function (see section 5.3). The use of Amisulpride is not recommended during pregnancy and in women of childbearing potential not using effective contraception, unless the expected benefits justify the potential risks involved. Newborns exposed to antipsychotics (including amisulpride) during the third trimester of pregnancy, are at risk of adverse events including extrapyramidal symptoms and / or withdrawal symptoms, which may vary in severity and duration after birth (see section 4.8). The following reactions have been reported: agitation, hypertonia, hypotonia, tremors, drowsiness, respiratory distress, eating disorders. As a result, newborns should be closely monitored.

Breastfeeding

Amisulpride is excreted in breast milk in a fairly large amount, in some cases exceeding the accepted value of 10% of the dosage adjusted for the weight of the mother, but the concentrations in the blood in breast-fed infants have not been evaluated. There is insufficient information on the effects of amisulpride in newborns / infants. You should decide whether to stop breastfeeding or not take amisulpride taking into account the benefit of breastfeeding for the child and the benefit of the treatment for the woman.

Fertility

A decrease in fertility linked to the pharmacological effects of the drug (prolactin-dependent effect) has been observed in treated animals.

Attention is drawn, in particular to drivers of vehicles and users of machines, to the risk of drowsiness and blurred vision associated with the use of this medicine (see section 4-8).

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.

Post-Marketing data

In addition, cases of the following adverse reactions have been reported through spontaneous reporting only:

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 Website at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

Experience with Amisulpride 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 Amisulpride is weakly dialysed, hemodialysis is of no use to eliminate the drug.

There is no specific antidote to Amisulpride.

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.

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, adrenergic, histamine H₁ 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 Amisulpride against both negative and positive symptoms of schizophrenia.

Absorption

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. Absolute bioavailability is 48%.

A carbohydrate rich meal (containing 68% fluids) significantly decreases the AUCs, T_max and C_max 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.

Distribution

The volume of distribution is 5.8 l/kg, plasma protein binding is low (16%) and no drug interactions are suspected.

Metabolism

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.

Elimination

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. The elimination half-life of amisulpride is approximately 12 hours after an oral dose.

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 section 4.2). Experience is however limited and there is no data with doses greater than 50 mg.

Amisulpride is very weakly dialysed.

Elderly

Limited pharmacokinetic data in elderly subjects (> 65 years) show that a 10-30 % rise occurs in C_max, T_1/2 and AUC after a single oral dose of 50 mg. No data are available after repeat dosing.

An overall review of the completed safety studies indicates that Amisulpride 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/day) and dog (120 mg/kg/day) 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/day) and reproductive studies (160, 300 and 500 mg/kg/day respectively in rat, rabbit and mouse) were performed. The exposure of the animals to amisulpride during these latter studies was not evaluated.

Saccharin sodium (E954)

Sodium gluconate (E576)

Glucono-delta-lactone (E575)

Hydrochloric acid, concentrated (E507)

Methyl parahydroxybenzoate (E218)

Caramel flavour (containing propylene glycol (E1520))

Purified water

In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.

24 months

Discard 60 days after first opening.

This medicinal product does not require any special storage conditions.

For storage conditions after first opening of the medicinal product, see section 6.3.

Bottle: Ph.Eur. Type III amber glass bottle

Closure: Child resistant, tamper evident plastic (polyethylene/polypropylene) cap with EPE liner

Dosing Device: 5ml oral syringe with 0.5ml graduation

Pack Size: 60ml

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.

Syri Limited,

Unit 4, Bradfield Road,

Ruislip, Middlesex,

HA4 0NU, UK

Trading as:

Thame Laboratories,

Unit 4, Bradfield Road,

Ruislip, Middlesex,

HA4 0NU, UK

OR

Trading as:

SyriMed,

Unit 4, Bradfield Road,

Ruislip, Middlesex,

HA4 0NU, UK.

PL 39307/0070

Date of first authorisation: 07 December 2016

Common Renewal date: 06 December 2021

07/09/2021