PARACETAMOL BIOGARAN 1000 mg Effervescent Tablet Tube/8

Paracetamol........................................................................................................................................ 1000,00 mg

In the form of paracetamol COMPAP PVP 3............................................................................... 1031,00 mg

For one scored effervescent tablet.

Excipients with known effect: lactose, sodium, sorbitol.

Symptomatic treatment of mild to moderate pain and/or fever.

Adults and children from 50 kg (approximately 15 years).

Dosage

Warning: this presentation contains 1000 mg (1 g) of paracetamol per scored effervescent tablet: do not take 2 tablets at a time.

Use the lowest effective dose for the shortest possible duration. Use a dose of 1000 mg for pain and/or fever not relieved by a dose of 500 mg of paracetamol.

Recommended dosage: approximately 60 mg/kg/day to be divided into several doses, without exceeding the maximum dose indicated in the table below.

The approximate age according to weight is given for information only.

Warning: Take into account all medicines containing paracetamol to avoid overdose, including those obtained without a prescription.

Only on medical advice and in the absence of concomitant risk factors, the dosage may be increased up to 4000 mg (4 g) per day, i.e. 4 effervescent tablets per day, in patients weighing at least 50 kg (approximately 15 years old).

Special populations

The maximum daily dose must not exceed 60 mg/kg/day nor exceed 3000 mg per day (3 g/day) in the following situations:

• Adults weighing less than 50 kg,

• In cases of low reserves or hepatic glutathione deficiency (e.g. chronic malnutrition, fasting, recent weight loss, anorexia, cachexia),

• Dehydration.

Hepatic insufficiency (mild to moderate), chronic alcoholism and Gilbert's syndrome (familial non-haemolytic jaundice)

 It is recommended to reduce the dose and increase the minimum interval between two doses. The daily dose of paracetamol must not exceed 2000 mg/day (2 g/day).

Renal impairment

In case of renal insufficiency and unless medically advised, it is recommended to reduce the maximum daily dose and increase the minimum interval between 2 doses according to the table below.

Adults:

Elderly

Clinical experience indicates that the recommended dosage is generally adequate in adults. However, concomitant risk factors, some of which occur more frequently in elderly subjects and which require dose adjustment, should be taken into account.

Method of administration

Oral use.

Let dissolve completely Dissolve the tablet in a glass of water. Drink immediately afterwards.

Duration of treatment

Frequent or prolonged use without medical supervision is not recommended.

If symptoms persist beyond 5 days in the case of pain or 3 days in the case of fever, if symptoms worsen or if new symptoms appear, treatment should be re-evaluated.

• Hypersensitivity to paracetamol or to any of the excipients mentioned in section Composition.

• Severe hepatic impairment.

Due to the unit dose of paracetamol per scored effervescent tablet (1000 mg, i.e. 1 g), this presentation is not suitable for children under 50 kg.

Patients must be informed that they must not take other medicines containing paracetamol. Taking several doses at one administration may seriously damage the liver; if this occurs, the patient must immediately call a doctor.

In a child treated with 60 mg/kg/day of paracetamol, the combination with another antipyretic is only justified in case of ineffectiveness.

In case of acute viral hepatitis, treatment should be stopped.

Precautions for use

Paracetamol must be administered with caution in the following situations (see section Dosage and administration) :

• Adult with a weight of less than 50 kg

• Mild to moderate hepatic insufficiency

• Chronic alcoholism and recent withdrawal

• Renal insufficiency

• Gilbert's syndrome

• Concomitant treatment with medicines affecting liver function (e.g.: potentially hepatotoxic medicines, cytochrome P450 enzyme-inducing medicines such as phenobarbital, phenytoin, carbamazepine, topiramate, rifampicin)

• Deficiency in Glucose-6-Phosphate Dehydrogenase (G6PD) (which may lead to haemolytic anaemia)

• Dehydration

• In cases of low reserves or hepatic glutathione deficiency (e.g. chronic malnutrition, fasting, recent weight loss, anorexia, cachexia)

• Elderly people

Consumption of alcoholic beverages during treatment is not recommended.

With long-term use, high doses, or incorrect use of analgesics in patients with chronic headaches, headaches may appear or worsen; they must not be treated with higher doses of this medicine. In such cases, use of analgesics should be discontinued on medical advice.

Cases of high anion gap metabolic acidosis (HAGMA) due to pyroglutamic acidosis have been reported in patients with serious illnesses such as severe renal failure and sepsis, or in patients suffering from malnutrition or other sources of glutathione deficiency (for example, chronic alcoholism), who have been treated with paracetamol at therapeutic doses for an extended period or with a combination of paracetamol and flucloxacillin. In case of suspected HAGMA due to pyroglutamic acidosis, it is recommended to immediately discontinue paracetamol and to carry out close monitoring. Measurement of urinary 5-oxoproline may be useful to identify pyroglutamic acidosis as the underlying cause of HAGMA in patients presenting with multiple risk factors.

Excipients with known effect

This medicine contains 200 mg of sorbitol per tablet. Sorbitol is a source of fructose. Patients with hereditary fructose intolerance (HFI) must not take/receive this medicine.

This medicine contains lactose. Patients with galactose intolerance, total lactase deficiency or glucose-galactose malabsorption syndrome (rare hereditary diseases) must not take this medicine.

This medicine contains 331 mg of sodium per effervescent tablet, equivalent to 16,55 % of the World Health Organization's maximum recommended daily sodium intake. The maximum daily dose of this product (4 tablets) is equivalent to 66,2 % of the World Health Organization's maximum recommended daily sodium intake. PARACETAMOL BIOGARAN 1000 mg, scored effervescent tablet has a high sodium content. To be taken into account in people on a low-sodium diet.

Associations requiring precautions for use

+ Vitamin K antagonists

Risk of increased effect of the vitamin K antagonist and of bleeding risk when paracetamol is taken at maximum doses (4 g/day) for at least 4 days.

More frequent INR monitoring. Possible adjustment of the vitamin K antagonist dose during paracetamol treatment and after its discontinuation.

+ Flucloxacillin

Caution should be exercised when paracetamol and flucloxacillin are used concomitantly, as simultaneous use has been associated with high anion gap metabolic acidosis due to pyroglutamic acidosis, particularly in patients with risk factors (see section Warnings and precautions).

Interactions with paraclinical tests

Taking paracetamol may distort blood glucose measurement by the glucose oxidase-peroxidase method in cases of abnormally high concentrations.

Taking paracetamol may distort the measurement of blood uric acid by the phosphotungstic acid method.

Pregnancy

A large amount of data on pregnant women shows the absence of any malformation or any fetal/neonatal toxicity.

Epidemiological studies on the neurodevelopment of children exposed to paracetamol in utero produce inconclusive results.

If clinically necessary, paracetamol may be used during pregnancy; however, it should be used at the lowest effective dose, for the shortest possible duration and at the lowest possible frequency.

Breast-feeding

After administration, paracetamol is excreted in small quantities in breast milk. At therapeutic doses, administration of this medicine is possible during breastfeeding.

Fertility

Because of its potential mechanism of action on cyclo-oxygenases and prostaglandin synthesis, paracetamol could impair fertility in women, through an effect on ovulation that is reversible upon discontinuation of treatment.

Effects on male fertility have been observed in an animal study. The relevance of these effects in humans is not known.

Paracetamol has no or negligible effect on the ability to drive vehicles and use machines.

Undesirable effects are classified by system organ class. Their frequencies are defined as follows:

• Very common (≥ 1/10)

• Common (≥ 1/100 to < 1/10)

• Uncommon (≥ 1/1000 to < 1/100)

• Rare (≥ 1/10 000 to < 1/1000)

• Very rare (< 1/10 000)

• Frequency not known (cannot be estimated from the available data)

Description of selected adverse reactions

High anion gap metabolic acidosis

Cases of high anion gap metabolic acidosis due to pyroglutamic acidosis have been observed in patients with risk factors taking paracetamol (see section Warnings and precautions). Pyroglutamic acidosis may occur in these patients due to low glutathione levels.

Reporting of suspected adverse reactions

Reporting of suspected adverse reactions after registration of the medicine is important. It allows continuous monitoring of the benefit/risk balance of the medicine. Healthcare professionals report any suspected adverse reaction via the national reporting system: National Agency for the Safety of Medicines and Health Products (ANSM) and network of Regional Pharmacovigilance Centres - Website: https://signalement.social-sante.gouv.fr/

The risk of severe poisoning (therapeutic overdose or accidental poisoning) may be particularly high in elderly subjects, young children, patients with hepatic or renal impairment, in cases of chronic alcoholism, in patients suffering from chronic malnutrition (see section Dosage and administration), fasting, recent weight loss, familial cholemia (Gilbert's syndrome), as well as patients receiving enzyme-inducing medicines. In these cases, poisoning may be fatal.

Symptoms

Nausea, vomiting, anorexia, pallor, malaise, sweating, abdominal pain generally appear within 24 first hours.

An overdose may cause hepatic cytolysis that may lead to hepatocellular insufficiency that may require a liver transplant, gastrointestinal bleeding, metabolic acidosis, encephalopathy that may extend to coma and death.

Cases of disseminated intravascular coagulation have been observed in the context of paracetamol overdose.

Simultaneously, an increase in hepatic transaminases, lactate dehydrogenase, and bilirubin, and a decrease in prothrombin level may be observed 12 to 48 hours after ingestion. Clinical symptoms of liver involvement are generally observed after 1 to 2 days, and reach a maximum after 3 to 4 days.

Overdose may also lead to acute pancreatitis, hyperamylasemia, acute renal failure and pancytopenia.

Emergency management

• Discontinue treatment.

• Immediate transfer to a hospital setting for emergency medical care, despite the absence of significant early symptoms.

• Rapid evacuation of the ingested product, by aspiration and gastric lavage, preferably within 4 hours following ingestion.

• Blood sampling to perform the initial plasma paracetamol assay. The plasma concentration of paracetamol must be measured at least 4 hours after ingestion (an assay performed earlier is not reliable).

• Treatment of overdose conventionally includes administration of the antidote N-acetylcysteine as early as possible, intravenously or orally if possible. before the tenth hour. Although less effective, a protective effect of the antidote may be obtained up to 48 hours post-ingestion. In this case the antidote must be administered for a longer period.

• Symptomatic treatment.

• Liver tests must be performed at the start of treatment and repeated every 24 hours. In most cases, hepatic transaminases return to normal within 1 to 2 weeks with full restoration of liver function. However, in very severe cases, liver transplantation may be necessary.

• Further measures will depend on the severity, nature and course of the clinical symptoms of paracetamol poisoning and should follow standard intensive care protocols.

Pharmacotherapeutic class: OTHER ANALGESICS and ANTIPYRETICS-ANILIDES.

ATC code: N02BE01.

Paracetamol has a central and peripheral mechanism of action.

Absorption

Oral absorption of paracetamol is complete and rapid. Maximum plasma concentrations are reached 30 to 60 minutes after ingestion.

Distribution

Paracetamol is rapidly distributed in all tissues. Concentrations are comparable in blood, saliva and plasma. Binding to plasma proteins is low.

Biotransformation

Paracetamol is metabolised mainly in the liver. The 2 major metabolic pathways are glucuronidation and sulfoconjugation. The latter pathway is rapidly saturable at doses above therapeutic doses. A minor pathway, catalysed by cytochrome P450, is the formation of a reactive intermediate (N-acetyl benzoquinone imine), which under normal conditions of use is rapidly detoxified by reduced glutathione and eliminated in the urine after conjugation with cysteine and mercapturic acid. In contrast, during massive overdoses, the quantity of this toxic metabolite is increased.

Elimination

Elimination is mainly urinary. 90% of the ingested dose is eliminated by the kidney within 24 hours, mainly in glucuronide-conjugated form (60 to 80%) and sulfate-conjugated form (20 to 30%).

Less than 5% is eliminated in unchanged form.

The elimination half-life is approximately 2 hours.

Pathophysiological variations

Renal impairment (see section Dosage and administration) : elimination of paracetamol and its metabolites is delayed.

Hepatic impairment: paracetamol metabolism is impaired in patients with chronic hepatic impairment, as shown by increased plasma paracetamol concentrations and a longer elimination half-life (see section Dosage and administration).

Elderly subjects: the conjugation capacity is not modified (see section Dosage and administration).

No conventional study based on currently accepted standards for assessing reproductive and developmental toxicity is available.

3 years.

Store the primary container tightly closed, protected from moisture.

No special requirements.