Source: Health Products Regulatory Authority (ZA) Revision Year: 2022 Publisher: PHARMACARE LIMITED, Healthcare Park, Woodlands Drive, Woodmead, 2191
ARTHREXIN is contraindicated in:
Safety of ARTHREXIN in children has not been established.
ARTHREXIN may predispose to cardiovascular events, gastrointestinal events, or cutaneous reactions which may be fatal.
Serious skin reactions, some of them fatal, including drug rash with eosinophilia and systemic symptoms (DRESS), exfoliative dermatitis, Stevens-Johnson syndrome, and toxic epidermal necrolysis (TEN) have been reported (see section 4.8). These serious events may occur without warning. Patients should be informed about the signs and symptoms of serious skin manifestations.
Patients allergic to salicylates may exhibit a cross-reaction to ARTHREXIN. ARTHREXIN should be discontinued at the first appearance of skin rash, mucosal lesions, or any other sign of hypersensitivity.
Patients should be carefully observed to detect any unusual manifestations of medicine sensitivity.
Patients appear to be at highest risk for these reactions early in the course of treatment, the onset of the reaction occurring in the majority of cases, within the first month of treatment.
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) has been reported in patients taking NSAIDs such as ARTHREXIN. Some of these events have been fatal or life-threatening. DRESS typically, although not exclusively, presents with fever, rash, lymphadenopathy, and/or facial swelling. Other clinical manifestations may include hepatitis, nephritis, haematological abnormalities, myocarditis, or myositis. Sometimes symptoms of DRESS may resemble an acute viral infection. Eosinophilia is often present. Because this disorder is variable in its presentation, other organ systems not noted here may be involved. It is important to note that early manifestations of hypersensitivity, such as fever or lymphadenopathy, may be present even though rash is not evident. If such signs or symptoms are present, discontinue ARTHREXIN and evaluate the patient immediately.
The risk of gastrointestinal bleeding or perforation (PUBs) is higher with increasing doses of ARTHREXIN, in patients with a history of ulcers, and the elderly. These patients should commence treatment on the lowest dose available. When gastrointestinal bleeding or ulceration occurs in patients receiving ARTHREXIN, treatment with ARTHREXIN should be stopped.
ARTHREXIN should be given with caution to patients with a history of gastrointestinal disease (e.g., ulcerative colitis, Crohn’s disease, hiatus hernia, gastro-oesophageal reflux disease, angiodysplasia) as the condition may be exacerbated. Combination treatment with protective medicines (e.g., misoprostol or proton pump inhibitors) should be considered for these patients, and also for patients requiring concomitant low dose aspirin.
Single or multiple ulcerations, including perforation and haemorrhage of the oesophagus, stomach, duodenum or small or large intestine, have been reported to occur with ARTHREXIN. Fatalities have been reported. Intestinal ulceration has been associated with stenosis and obstruction (see section 4.8).
Gastrointestinal bleeding without obvious ulcer formation and perforation of preexisting sigmoid lesions (diverticulum, carcinoma, etc.) have occurred. Increased abdominal pain in patients with ulcerative colitis or the development of ulcerative colitis and regional ileitis have been reported (see section 4.8).
Caution is required in patients with a history of cardiac dysfunction, hypertension and/or heart failure as fluid retention and oedema have been reported in association with ARTHREXIN treatment due to inhibition of prostaglandin synthesis. In view of ARTHREXIN’s inherent potential to cause fluid retention, heart failure may be precipitated in some compromised patients.
Appropriate monitoring and advice are required for patients with a history of hypertension and/or mild to moderate congestive heart failure as fluid retention and oedema have been reported in association with NSAID treatment, as in ARTHREXIN.
Patients with uncontrolled hypertension, congestive heart failure, established ischaemic heart disease, peripheral arterial disease, and/or cerebrovascular disease should not be treated with indomethacin, as in ARTHREXIN (see section 4.3). Caution is required before initiating longer-term treatment of patients with significant risk factors for cardiovascular disease (e.g., hypertension, hyperlipidaemia, diabetes mellitus, smoking).
ARTHREXIN, can lead to onset or exacerbation of hypertension, either of which may contribute to the increased incidence of cardiovascular events. Patients taking thiazides or loop diuretics may have impaired response to these therapies when taking NSAIDs, as in ARTHREXIN. ARTHREXIN, should be taken with caution in patients with hypertension.
Blood pressure (BP) should be monitored closely during the initiation of NSAID treatment, as in ARTHREXIN and throughout the course of treatment.
ARTHREXIN and other NSAIDs may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal. Both COX-2 selective and nonselective, may have a similar risk. This risk may increase with duration of use.
Patients with cardiovascular disease or risk factors for cardiovascular disease may be at greater risk. To minimise the potential risk for an adverse cardiovascular event in patients treated with ARTHREXIN, the lowest effective dose should be taken for the shortest duration possible.
Because of its lack of platelet effect, ARTHREXIN is not a substitute for aspirin for cardiovascular prophylaxis.
In patients with renal, cardiac, hepatic impairment, hypertension, heart failure or conditions predisposing to fluid retention, caution is required since the use of NSAIDs, as in ARTHREXIN, may result in deterioration of renal function (see section 4.8). The dose should be kept as low as possible and renal function should be monitored. ARTHREXIN may also cause fluid retention which may further aggravate these conditions.
In patients with reduced renal blood flow where renal prostaglandins play a major role in maintaining renal perfusion, administration of a NSAID, as in ARTHREXIN, may precipitate overt renal decompensation. The administration of an NSAID, as in ARTHREXIN, may cause a dose dependent reduction in prostaglandin formation and precipitate renal failure. Patients at greatest risk of this reaction are those with renal or hepatic dysfunction, diabetes mellitus, advanced age, extracellular volume depletion, congestive heart failure, sepsis, or concomitant use of any nephrotoxic medicines.
Caution should be used when initiating the treatment with ARTHREXIN in patients with dehydration. Patients should first be hydrated before treatment with ARTHREXIN commences.
Caution is also recommended in patients with pre-existing kidney disease. ARTHREXIN should be given with caution and renal function should be monitored in any patient who may have reduced renal reserve (see also section 4.3). Discontinuation of NSAID treatment, as in ARTHREXIN, is usually followed by recovery to the pre-treatment state.
Acute interstitial nephritis with haematuria, proteinuria, and occasionally nephrotic syndrome can occur in patients receiving long-term administration of ARTHREXIN. Since indomethacin, as in ARTHREXIN, is eliminated primarily by the kidneys, patients with significantly impaired renal function should not be treated with ARTHREXIN (see section 4.3).
Increases in plasma potassium concentration, including hyperkalaemia, can occur even in some patients without renal impairment. In patients with normal renal function, these effects have been attributed to a hyporeninaemic-hypoaldosteronism state.
ARTHREXIN may cause a rise in liver enzymes. Significant (3 times the upper limit of normal) elevations of ALT (SGPT) or AST (SGOT) in controlled clinical trials have been reported in less than 1% of patients receiving treatment with NSAIDs such as ARTHREXIN.
A patient with symptoms and/or signs suggesting liver dysfunction, or in whom an abnormal liver test has occurred, should be evaluated for evidence of development of more severe hepatic reactions while on treatment with ARTHREXIN.
If abnormal liver tests persist or worsen, if clinical signs and symptoms consistent with liver disease develop, or if systemic manifestations occur (e.g., eosinophilia, rash, etc.), treatment should be discontinued.
Limit the use of NSAIDs, including ARTHREXIN, between 20 and 30 weeks of pregnancy due to the risk of oligohydramnios/foetal renal dysfunction. Avoid use of NSAIDs, such as ARTHREXIN, in women around 30 weeks gestation and later in pregnancy due to the risks of oligohydramnios/foetal renal dysfunction and premature closure of the foetal ductus arteriosus (see section 4.3 and 4.6).
These adverse outcomes are seen, on average, after days to weeks of treatment, although oligohydramnios has been infrequently reported as soon as 48 hours after NSAID, such as ARTHREXIN, initiation. Oligohydramnios is often, but not always, reversible with treatment discontinuation. Complications of prolonged oligohydramnios may include limb contractures and delayed lung maturation. In some post marketing cases of impaired neonatal renal function, invasive procedures such as exchange transfusion or dialysis were required.
If ARTHREXIN is necessary between 20 weeks and 30 weeks gestation, limit ARTHREXIN use to the lowest effective dose and shortest duration possible. Healthcare professionals should consider ultrasound monitoring of amniotic fluid if ARTHREXIN treatment extends beyond 48 hours. Discontinue ARTHREXIN if oligohydramnios occurs and follow up according to clinical practice.
ARTHREXIN may have a reversible inhibitory effect on women’s ovulation. The use of ARTHREXIN may impair female fertility and is not recommended in women attempting to conceive. In women who have difficulties conceiving or who are undergoing investigation of infertility, withdrawal of ARTHREXIN should be considered (see section 4.6).
In patients with systemic lupus erythematosus (SLE) and mixed connective tissue disorders there may be an increased risk of aseptic meningitis.
After long-term treatment with analgesics, medication-overuse headache (MOH) may develop or be aggravated. MOH should be suspected in patients who have frequent or daily headaches despite (or because of) regular use of analgesics. Patients with MOH should not be treated by increasing the dose. In such cases the use of analgesics should be discontinued in consultation with a doctor.
Corneal deposits and retinal disturbances, including those of the macula, have been observed in patients who had received prolonged treatment with ARTHREXIN. In patients with rheumatoid arthritis, eye changes may occur which may be related to the underlying disease or to the treatment. In chronic rheumatoid disease, ophthalmological examinations at periodic intervals are recommended, treatment should be discontinued if eye changes are observed.
Blurred vision may be a significant symptom and warrants a thorough ophthalmological examination. Since these changes may be asymptomatic, ophthalmological examination at periodic intervals is desirable in patients where treatment is prolonged.
Discontinue treatment if eye changes are observed.
Prolonged treatment will require regular ophthalmological examination.
ARTHREXIN can inhibit platelet aggregation. This effect usually disappears within 24 hours of discontinuation of ARTHREXIN. ARTHREXIN has been shown to prolong bleeding time (but within the normal range) in normal adults. Because this effect may be exaggerated in patients with underlying homeostatic defects, ARTHREXIN should be used with caution in persons with coagulation defects (see section 4.5).
Caution is required when ARTHREXIN is administered to patients suffering from, or with a previous history of bronchial asthma, since NSAIDs, as in ARTHREXIN, have been reported to precipitate bronchospasm in such patients.
Headache, sometimes accompanied by dizziness or light-headedness may occur, usually early in treatment with ARTHREXIN.
Starting treatment with a low dosage and increasing it gradually may minimise the incidence of headache. These symptoms may disappear on continuing treatment or with reducing the dosage. If headache persists despite dosage reduction, ARTHREXIN should be withdrawn.
ARTHREXIN may mask the signs and symptoms which ordinarily accompany infectious disease.
ARTHREXIN should be used with caution in patients with existing, but controlled infection.
Caution is advised with concomitant use of live vaccines.
Patients should be periodically observed to allow early detection of any unwanted effects on peripheral blood (anaemia), liver function, or gastro-intestinal tract.
ARTHREXIN should be used cautiously in patients with psychiatric disorders, epilepsy or Parkinsonism, as indomethacin, as in ARTHREXIN, may aggravate these disorders.
Safety has not been established.
The elderly have an increased frequency of adverse reactions to NSAIDs, including ARTHREXIN, especially gastrointestinal bleeding and perforation (PUBs) which may be fatal. An increase in age increases the possibility of side effects. ARTHREXIN should be used with greater care in the elderly.
The safety and efficacy of ARTHREXIN in children has not yet been established (see section 4.3).
If ARTHREXIN fails to provide benefit in 2 to 3 weeks, alternative treatment must be considered.
ARTHREXIN contains lactose which may have an effect on the glycaemic control of patients with diabetes mellitus.
Patients with rare hereditary conditions of galactose intolerance total lactase deficiency or glucose-galactose malabsorption should not take ARTHREXIN.
When diflunisal and ARTHREXIN are given together, the renal clearance of ARTHREXIN decreases and the plasma concentration increases, and the combined use can result in fatal gastrointestinal haemorrhage. The combination should not be used (see section 4.3).
The administration of anti-inflammatory doses of aspirin decreases ARTHREXIN blood concentrations by about 20%.
ARTHREXIN inhibits platelet aggregation but is not a substitute for aspirin for cardiovascular prophylaxis.
There is no consistent evidence that concurrent use of aspirin mitigates the increased risk of serious cardiovascular thrombotic events associated with ARTHREXIN. The concomitant use of ARTHREXIN with aspirin or other salicylates is not recommended. Combined use of ARTHREXIN and aspirin does not produce any greater therapeutic effect than the use of ARTHREXIN. Furthermore, the incidence of gastrointestinal side effects significantly increases with combined treatment.
The use of two or more NSAIDs concomitantly could result in the increase in side effects and should therefore be avoided.
The bioavailability of indomethacin, as in ARTHREXIN, may be reduced by concomitant antacid treatment.
When indomethacin, as in ARTHREXIN, is given to patients receiving probenecid, the plasma levels of indomethacin, as in ARTHREXIN are likely to be increased. Therefore, a lower total daily dosage of indomethacin, as in ARTHREXIN, may produce a satisfactory therapeutic effect. When increases in the dose of indomethacin, as in ARTHREXIN, are made under these circumstances they should be made cautiously and in small increments.
ARTHREXIN may enhance the effects of anticoagulants such as warfarin. Patients should be closely observed for alterations of prothrombin time, when indomethacin, as in ARTHREXIN is given concomitantly with anticoagulants. Caution should be exercised when indomethacin, as in ARTHREXIN and anticoagulants are administered concomitantly.
Concurrent administration of oral anticoagulant medicines leads to increased risk of gastrointestinal bleeding.
Increased risk of gastrointestinal ulceration or bleeding (PUBs). In a patient receiving corticosteroids concomitantly, a reduction in dosage of these may be possible, but should only be effected slowly under supervision.
Increased risk of gastrointestinal bleeding. Indomethacin, as in ARTHREXIN can inhibit platelet aggregation, an effect which disappears within 24 hours of discontinuation; the bleeding time may be prolonged, and this effect may be exaggerated in patients with an underlying haemostatic defect (see section 4.4).
Increased risk of bleeding.
The hypoglycaemic effect of sulfonylureas may be increased by NSAIDs, such as ARTHREXIN.
Caution should be exercised with concomitant use of indomethacin, as in ARTHREXIN, with methotrexate. Indomethacin, as in ARTHREXIN, has been reported to decrease the tubular secretion of methotrexate and thereby to potentiate methotrexate toxicity.
Serious interactions have been reported with the use of high doses of methotrexate with indomethacin, as in ARTHREXIN.
Administration of NSAIDs such as ARTHREXIN, concomitantly with ciclosporin has been associated with an increase in ciclosporin-induced toxicity, possibly due to decreased synthesis of renal prostacyclin. Indomethacin, as in ARTHREXIN should be used with caution in patients taking ciclosporin, and renal function should be monitored carefully.
Decreased elimination of lithium; Indomethacin, as in ARTHREXIN, inhibits prostaglandin synthesis and may therefore raise plasma lithium levels and reduce lithium clearance in patients with steady state plasma lithium concentrations. At the onset of such combined treatment, plasma lithium concentration should be monitored more frequently.
Reduced anti-hypertensive effect; ARTHREXIN may acutely reduce the antihypertensive effect of antihypertensives due partly to the inhibition of prostaglandin synthesis of indomethacin, as in ARTHREXIN. Patients receiving concomitant treatment should have the antihypertensive effect of their treatment reassessed. Therefore, caution should be exercised when considering the addition of indomethacin, as in ARTHREXIN, to the regimen of a patient taking any of the following antihypertensive medicines:
An increased risk of hyperkalaemia has also been reported when NSAIDs such as ARTHREXIN, are taken with ACE inhibitors.
ARTHREXIN may increase the effects of phenytoin.
Increased drowsiness has been reported with concomitant use of ARTHREXIN and haloperidol.
There is an increased risk of haematological toxicity when NSAIDs, such as ARTHREXIN are given with zidovudine. There is evidence of an increased risk of haemarthroses and haematoma in HIV haemophiliacs receiving concurrent treatment with zidovudine and ibuprofen. There is a risk of indomethacin toxicity with concomitant use of ARTHREXIN with ritonavir and should thus be avoided. False negative results in the dexamethasone suppression test have been reported in patients taking ARTHREXIN.
ARTHREXIN antagonises the natriuretic and antihypertensive effects of furosemide, the antihypertensive effects of thiazide diuretics, ß-adrenergic blocking medicines, or inhibitors of angiotensin converting enzyme may also be reduced. Therefore, when ARTHREXIN and diuretics are used concomitantly, the patient should be closely observed to determine whether the desired effect of the diuretic is being obtained.
Reversible acute renal failure associated with the concomitant administration of indomethacin, as in ARTHREXIN and triamterene has been reported. Indomethacin, as in ARTHREXIN and triamterene should not be administered concomitantly. The risk of acute renal insufficiency, which is usually reversible, may be increased with compromised renal function (e.g., dehydrated patients or elderly patients) when angiotensin II receptor antagonists are combined with NSAIDs such as ARTHREXIN. Therefore, the combination should be administered with caution, especially in the elderly. Patients should be adequately hydrated, and consideration should be given to monitoring of renal function after initiation of concomitant treatment, and periodically thereafter.
Diuretics can increase the risk of nephrotoxicity of NSAIDs, such as ARTHREXIN. In patients with compromised renal function (e.g., the elderly or patients who are volume depleted, including those on diuretic treatment) who are being treated with NSAIDs, such as ARTHREXIN, including selective cyclooxygenase-2 inhibitors, the co- administration of angiotensin II receptor antagonists or ACE inhibitors may result in further deterioration of renal function, including possible acute renal injury (renal failure). These effects are usually reversible. Therefore, the combination should be administered with caution in patients with compromised renal function. Both indomethacin, as in ARTHREXIN and potassium-sparing diuretics may be associated with increased serum potassium levels. The potential effects of indomethacin, as in ARTHREXIN and potassium-sparing diuretics on potassium kinetics and renal function should be considered when these medicines are administered concurrently. Most of the above effects relating to diuretics have been attributed at least in part, to mechanisms involving inhibition of prostaglandin synthesis in indomethacin, as in ARTHREXIN.
ARTHREXIN given concomitantly with digoxin has been reported to increase the serum concentration and prolong the half-life of digoxin. Therefore, when indomethacin, as in ARTHREXIN and digoxin are used concomitantly, plasma digoxin levels should be closely monitored.
NSAIDs, such as ARTHREXIN, may exacerbate cardiac failure, reduce GFR and increase plasma digoxin levels.
Hypertensive crises have been reported due to oral phenylpropanolamine, and to phenylpropanolamine given concomitantly with indomethacin, as in ARTHREXIN. This additive effect is probably due at least in part to inhibition of prostaglandin synthesis by indomethacin, as in ARTHREXIN and may lead to water intoxication. Caution should be exercised when indomethacin, as in ARTHREXIN and phenylpropanolamine are administered concomitantly.
Effect potentiated by indomethacin, as in ARTHREXIN and may lead to water intoxication.
NSAIDs, such as ARTHREXIN, and aspirin should be avoided until at least 8 to 12 days after administration of mifepristone as NSAIDs, such as ARTHREXIN, can reduce the effect of mifepristone.
Concomitant use of fluoroquinolones and indomethacin, as in ARTHREXIN may induce convulsions in patients with or without a history of convulsions/seizures.
Concomitant use of NSAIDs such as ARTHREXIN and baclofen may induce baclofen toxicity due to reduced rate of excretion.
Possible increased risk of bleeding when taken with NSAIDs such as ARTHREXIN.
Possible increased risk of nephrotoxicity when NSAIDs such as ARTHREXIN are given with tacrolimus.
The bioavailability of tiludronic acid is increased by indomethacin, as in ARTHREXIN.
False-negative results in the dexamethasone suppression test (DST) in patients being treated with indomethacin, as in ARTHREXIN have been reported. Thus, results of the DST should be interpreted with caution in these patients (see section 4.8).
The use of ARTHREXIN is contraindicated in pregnancy and lactation (see section 4.3).
Inhibition of prostaglandin synthesis may adversely affect the pregnancy and/or the embryo/foetal development.
Data from epidemiological studies suggests an increased risk of miscarriage and of cardiac malformation and gastroschisis after use of a prostaglandin synthesis inhibitor, such as ARTHREXIN, in early pregnancy. The absolute risk for cardiovascular malformation was increased from less than 1% up to approximately 1,5%. The risk is believed to increase with dose and duration of therapy. In animals, administration of a prostaglandin synthesis inhibitor has been shown to result in increased pre- and post- implantation loss and embryo-foetal lethality. In addition, increased incidences of various malformations, including cardiovascular, have been reported in animals given a prostaglandin synthesis inhibitor during the organogenetic period.
During the third trimester of pregnancy, all prostaglandin synthesis inhibitors
Because of these risks, the use of ARTHREXIN, dose and duration, between 20 and 30 weeks of gestation should be limited and avoided at around 30 weeks of gestation and later in pregnancy (see sections 4.3 and 4.4).
Indomethacin, as in ARTHREXIN is excreted into breast milk. Mothers breastfeeding their infants should not be treated with ARTHREXIN (see section 4.3).
The use of ARTHREXIN may impair female fertility and is not recommended in women attempting to conceive. In women who have difficulty conceiving or who are undergoing investigation of infertility, treatment with ARTHREXIN should be stopped (see section 4.4).
ARTHREXIN has major influence on the ability to drive or operate machinery. ARTHREXIN may interfere with driving and the operation of machines, as it may cause dizziness, drowsiness, visual disturbances and headaches. Patients on treatment with ARTHREXIN should not drive or operate machines until they know how they are affected by ARTHREXIN (see section 4.8).
The most common side effects are gastrointestinal disturbances, headache and dizziness. Gastrointestinal perforation, ulceration and bleeding, sometimes fatal, may occur.
| System organ class | Frequent | Less frequent | Frequency unknown (cannot be estimated from the available data) |
|---|---|---|---|
| Infections and infestations | Fulminant necrotising fasciitis1. | ||
| Neoplasm benign, malignant and unspecified (including cysts and polyps) | Leukaemia. | ||
| Blood and the lymphatic system disorders | Neutropenia, haemolytic anaemia, thrombocytopenia, agranulocytosis, leucopenia, aplastic anaemia, purpura, petechiae or ecchymosis, bone marrow depression, disseminated intravascular coagulation2. | ||
| Immune system disorders | Acute anaphylaxis. | Allergic reactions, anaphylaxis, skin rashes, itching, urticaria, pruritus, purpura, angioedema, erythema multiforme, acute asthma, aggravated asthma, rhinitis3. | |
| Endocrine disorders | Hyperglycaemia. | ||
| Metabolism and nutrition disorders | Hyperkalaemia. | ||
| Psychiatric disorders | Hallucinations, confusion, anxiety, depersonalisation4. | Depression. | |
| Nervous system disorders | Headache, dizziness, light headedness. | Drowsiness, insomnia, vertigo, fatigue (malaise and listlessness), syncope, convulsions, coma, peripheral neuropathy, dysarthria, epilepsy, parkinsonism, involuntary muscle movement, muscle weakness. | Aseptic meningitis5, aggravation of epilepsy and parkinsonism, paraesthesias4. |
| Eye disorders | Blurred vision, visual disturbances, optic neuritis, orbital and periorbital pain. | Corneal opacities, visualfield changes, pallor of the optic disc. | |
| Ear and labyrinth disorders | Tinnitus. hearing disturbances, deafness. | ||
| Cardiac disorders | Myocardial infarction, cardiovascular thrombotic events. | Peripheral oedema, cardiac failure, tachycardia, dysrhythmia, palpitations, congestive heart failure, chest pain. | |
| Vascular disorders | Hypertension, flushing, hypotension, thrombophlebitis. | ||
| Respiratory, thoracic and mediastinal disorders | Epistaxis acute respiratory distress, sudden dyspnoea, asthma, pulmonary oedema. | Pulmonary eosinophilia, bronchospasm. | |
| Gastrointestinal disorders | Epigastric distress, abdominal laceration6 | Acute pancreatitis, regional ileitis, anorexia, ulceration6 | Peptic ulcers, perforation, GI bleeding, nausea, vomiting, abdominal pain, diarrhoea, flatulence, constipation, dyspepsia, melaena, haematemesis, ulcerative stomatitis, exacerbation of colitis and Crohn’s disease, gastritis. |
| Hepatobiliary disorders | Hepatitis, jaundice. | Cholestasis, abnormal liver function7. | |
| Skin and subcutaneous tissue disorders | Erythema, angiitis, photosensitivity. | Exfoliative dermatitis. | Bullous reactions, including StevensJohnson syndrome and toxic epidermal necrolysis, Drug Rash with Eosinophilia and Systemic Syndrome (DRESS). angioneurotic oedema, alopecia, sweating, exacerbation of psoriasis. |
| Musculoskeletal and connective tissue disorders | Muscle weakness, acceleration of cartilage degeneration | ||
| Renal and urinary disorders | Glycosuria, urinary frequency. | Haematuria, renal failure8. | |
| Reproductive system and breast disorders | Vaginal bleeding, breast change including enlargement, tenderness or gynaecomastia. | ||
| General disorders and administrative site conditions | Weight gain, Oedema. | ||
| Investigations | BUN elevation. | A rapid fall in blood pressure resembling a shocklike state, false-negative results in the dexamethasone suppression test (DST). |
1,2,3,4,5,6,7,8 see c) below
1 Infections and infestations
Fulminant necrotising fasciitis, particularly in association with Group A β-haemolytic streptococcus.
2 Blood and the lymphatic system disorders
Blood dyscrasias may occur, including leukopenia, petechiae or ecchymosis, purpura, aplastic and haemolytic anaemia, agranulocytosis, bone marrow depression, disseminated intravascular coagulation, and thrombocytopenia. Patients may develop anaemia secondary to obvious appropriate blood determinations are recommended. Platelet function is impaired by ARTHREXIN.
3 Immune system disorders
Hypersensitivity reactions are manifested in skin rashes, itching, urticaria, and, more seriously, acute attacks of asthma.
Hypersensitivity reactions (a) non-specific allergic reactions and anaphylaxis, (b) respiratory tract reactivity comprising asthma, aggravated asthma, bronchospasm or dyspnoea, rhinitis (see section 4.3) or © assorted skin disorders, including rashes of various types, pruritus, urticaria, purpura, angioedema and exfoliative and bullous reactions, including Stevens-Johnson syndrome, toxic epidermal necrolysis and erythema multiforme).
4 Psychiatric disorders
Mental confusion, anxiety, psychic disturbances such as depersonalisation, psychotic episodes, paraesthesias; aggravation of psychiatric disturbances,
Nervous system disorders
Severe frontal headache may occur in patients using ARTHREXIN for long periods.
5Aseptic meningitis, (especially in patients with existing autoimmune disorders, such as systemic lupus erythematosus or mixed connective tissue disease) with symptoms such as stiff neck, headache, nausea, vomiting, fever or disorientation depression, vertigo, fatigue, malaise, dysarthria, coma, cerebral oedema, nervousness, confusion, anxiety and other psychiatric disturbances, depersonalisation, hallucinations, drowsiness, convulsions and aggravation of epilepsy and parkinsonism, peripheral neuropathy, paraesthesia, involuntary movements and insomnia.
6 Gastrointestinal disorders
Abdominal laceration, single or multiple, of oesophagus; stomach, duodenum or small or large intestine including perforation and haemorrhage. Ulceration at any point in the gastro-intestinal tract (even with resultant stenosis and obstruction), bleeding (even without obvious ulceration or from a diverticulum) and perforation of pre-existing sigmoid lesions (such as diverticulum or carcinoma), increased abdominal pain or exacerbation of the condition in patients with ulcerative colitis intestinal strictures and regional gastritis.
7 Hepato-biliary disorders
Borderline elevations of one or more liver tests may occur, and significant elevations of ALT (SGPT) or AST (SGOT),
8 Renal and urinary disorders
Nephrotoxicity in various forms, including interstitial nephritis, nephrotic syndrome, renal failure, renal insufficiency, proteinuria.
Reporting suspected adverse reactions after authorisation of the medicine is important. It allows continued monitoring of the benefit/risk balance of the medicine. Healthcare providers are asked to report any suspected adverse reactions to: SAHPRA: https://www.sahpra.org.za/health-products-vigilance/, Aspen Pharmacare: E-mail: Drugsafety@aspenpharma.com, Tel: 0800 118 088/<+27 (0)11 239-6200
Not applicable.
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