Source: Medicines & Healthcare Products Regulatory Agency (GB) Revision Year: 2020 Publisher: PL 08265/0003Daiichi Sankyo UK Ltd., 1<sup>st</sup> Floor, Building 4, Uxbridge Business Park, Sanderson Road, Uxbridge, UB8 1DH
Undesirable effects may be minimised by using the lowest effective dose for the shortest duration necessary to control symptoms (see section 4.2, and GI and cardiovascular risks below).
As with other NSAIDs, allergic reactions, including anaphylactic/anaphylactoid reactions, can also occur in rare cases with diclofenac without earlier exposure to the drug. Hypersensitivity reactions can also progress to Kounis syndrome, a serious allergic reaction that can result in myocardial infarction. Presenting symptoms of such reactions can include chest pain occurring in association with an allergic reaction to diclofenac. Motifene may mask the signs and symptoms of infection due to its pharmacodynamic properties.
The use of Motifene with concomitant NSAIDs including cyclo-oxygenase-2 selective inhibitors should be avoided due to the absence of any evidence demonstrating synergistic benefits and the potential for additive undesirable effects. (see section 4.5).
Caution is indicated on basic medical grounds. Older people have an increased frequency of adverse reactions to NSAIDs especially gastrointestinal bleeding and perforation which may be fatal (see section 4.2). It is recommended that the lowest effective dose be used in frail older people or those with a low body weight.
In patients with asthma, seasonal allergic rhinitis, swelling of the nasal mucosa (i.e. nasal polyps), chronic obstructive pulmonary diseases or chronic infections of the respiratory tract (especially if linked to allergic rhinitis-like symptoms), reactions to NSAIDs like asthma exacerbations (so-called intolerance to analgesics/analgesics-asthma), Quincke’s oedema or urticaria are more frequent than in other patients. Therefore, special precaution is recommended in such patients (readiness for a medical emergency). This is also applicable to patients who are known to be allergic to other substances and have previously presented with skin reactions, pruritus or urticaria.
Close medical surveillance is required when prescribing diclofenac to patients with impaired hepatic function, as their condition may be exacerbated.
As with other NSAIDs, treatment with diclofenac can be associated with a rise in liver enzymes. During prolonged treatment with diclofenac, regular monitoring of hepatic function is indicated as a precautionary measure. If abnormal liver function tests persist or worsen, or if clinical signs or symptoms consistent with liver disease develop, or if other manifestations occur (e.g. eosinophilia, rash), diclofenac should be discontinued. Hepatitis may occur without prodromal symptoms. Caution is called for in patients with hepatic porphyria, since it may trigger an attack.
Fluid retention and oedema have been reported with NSAID therapy, including diclofenac; particular caution is called for in patients with impaired cardiac or renal function, a history of hypertension, older people, patients receiving concomitant treatment with diuretics or medicinal products that can significantly impact renal function, and in those patients with substantial extracellular volume depletion from any cause, e.g. before or after major surgery (see section 4.3). Monitoring of renal function is recommended as a precautionary measure when using diclofenac in such cases. Discontinuation of therapy is usually followed by recovery to the pre-treatment state.
The administration of an NSAID may cause a dose dependent reduction in prostaglandin formation and precipitate renal failure. Patients at greatest risk of this reaction are those with impaired renal function, cardiac impairment, liver dysfunction, those taking diuretics and older people. Renal function should be monitored in these patients (see section 4.3).
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 therapy.
Clinical trial and epidemiological data suggest that use of diclofenac, particularly at high dose (150 mg daily) and in long term treatment may be associated with a small increased risk of arterial thrombotic events (for example myocardial infarction or stroke).
Diclofenac treatment for patients with uncontrolled hypertension and/or congestive heart failure (NYHA-I) should be given only after careful consideration.
Patients with significant risk factors for cardiovascular events (e.g. hypertension, hyperlipidaemia, diabetes mellitus, smoking) should only be treated with Motifene after careful consideration.
As the cardiovascular risks of diclofenac may increase with dose and duration of exposure, the shortest duration possible and the lowest effective daily dose should be used. The patient’s need for symptomatic relief and response to therapy should be re-evaluated periodically.
GI bleeding, ulceration or perforation, which can be fatal, has been reported with all NSAIDs at any time during treatment, with or without warning symptoms or a previous history of serious GI events.
The risk of GI bleeding, ulceration or perforation is higher with increasing NSAID doses, in patients with a history of ulcer, particularly if complicated with haemorrhage or perforation (see section 4.3), and in older people. These patients should commence treatment on the lowest dose available. Combination therapy with protective agents (e.g. misoprostol or proton pump inhibitors) should be considered for these patients, and also for patients requiring concomitant low dose aspirin, or other drugs likely to increase gastrointestinal risk (see below and section 4.5).
Patients with a history of GI toxicity, particularly when older, should report any unusual abdominal symptoms (especially GI bleeding) particularly in the initial stages of treatment.
Caution should be advised in patients receiving concomitant medications which could increase the risk of ulceration or bleeding, such as oral corticosteroids, anticoagulants such as warfarin, selective serotonin-reuptake inhibitors or anti-platelet agents such as aspirin (see section 4.5).
When GI bleeding or ulceration occurs in patients receiving Motifene, the treatment should be withdrawn.
NSAIDs should be given with care to patients with a history of gastrointestinal disease (ulcerative colitis, Crohn’s disease) as these conditions may be exacerbated (see section 4.8).
NSAIDs, including diclofenac, may be associated with increased risk of gastro-intestinal anastomotic leak. Close medical surveillance and caution are recommended when using diclofenac after gastro-intestinal surgery.
In patients with systemic lupus erythematosus (SLE) and mixed connective tissue disorders there may be an increased risk of aseptic meningitis (see section 4.8).
Serious skin reactions, some of them fatal, including exfoliative dermatitis, Stevens-Johnson syndrome, and toxic epidermal necrolysis, have been reported very rarely in association with the use of NSAIDs (see section 4.8). Patients appear to be at highest risk for these reactions early in the course of therapy: the onset of the reaction occurring in the majority of cases within the first month of treatment. Motifene should be discontinued at the first appearance of skin rash, mucosal lesions, or any other sign of hypersensitivity.
The use of Motifene 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 Motifene should be considered.
Diclofenac, in common with other NSAIDs, can reversibly inhibit platelet aggregation and with such patients, careful monitoring is advised.
Other analgesics including cyclo-oxygenase-2 selective inhibitors: Avoid concomitant use of two or more NSAIDs (including aspirin) as this may increase the risk of adverse effects (see section 4.4).
Diuretics and Anti-hypertensives: Reduced diuretic and anti-hypertensive effect may be seen
The combination should be administered with caution, and patients, especially older people, should have their blood pressure monitored. Patients should be adequately hydrated and renal function monitored after initiation of concomitant therapy and periodically thereafter, particularly for those patients on diuretics and ACE inhibitors, due to the increased risk of nephrotoxicity.
Diuretics can increase the risk of nephrotoxicity of NSAIDs. Concomitant treatment with potassium-sparing diuretics may be associated with increased serum potassium levels, hence serum potassium should be monitored.
Digoxin: A rise in plasma concentrations of dixogin may be seen, therefore monitoring of serum digoxin levels recommended.
Cardiac glycosides: NSAIDs may exacerbate cardiac failure, reduced GFR (Glomerular Filtration Rate) and increase plasma glycoside levels.
Lithium: Decreased elimination of lithium, may occur and monitoring of serum lithium levels recommended.
Methotrexate: Caution should be exercised if NSAIDs and methotrexate are administered within 24 hours of each other.
Diclofenac can inhibit the tubular renal clearance of methotrexate thereby increasing methotrexate levels, leading to toxicity.
Ciclosporin: Increased risk of nephrotoxicity, therefore diclofenac should be given at doses lower than those that would be used in patients not receiving ciclosporin.
Mifepristone: NSAIDs should not be used for 8-12 days after mifepristone administration as NSAIDs can reduce the effect of mifepristone.
Corticosteroids: Increased risk of gastrointestinal ulceration or bleeding (see section 4.4).
Anticoagulants and anti-platelet agents: Caution is recommended since concomitant administration could increase the risk of bleeding (see section 4.4). Although clinical studies do not appear to indicate that diclofenac affects the action of anticoagulants, there are reports of an increased risk of haemorrhage in patients receiving concomitant diclofenac and anticoagulants. Close monitoring of such patients is therefore recommended.
Quinolone antibiotics: Animal data indicate that NSAIDs can increase the risk of convulsions associated with quinolone antibiotics. Patients taking NSAIDs and quinolones may have an increased risk of developing convulsions.
Selective serotonin reuptake inhibitors (SSRIs): Increased risk of gastrointestinal bleeding (see section 4.4).
Tacrolimus: Possible increased risk of nephrotoxicity when NSAIDs are given with tacrolimus.
Zidovudine: Increased risk of haematological toxicity when NSAIDs 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.
Phenytoin: Monitoring of phenytoin plasma concentrations recommended due to an expected increase in phenytoin levels.
Colestipol and cholestyramine: These agents can induce a delay or decrease in absorption, therefore, it is recommended that diclofenac is administered at least one hour before or 4 to 6 hours after administration of colestipol/ cholestyramine.
Potent CYP2C9 inhibitors: Caution recommended when co-prescribing diclofenac with potent CYP2C9 inhibitors (such as sulfinpyrazone and voriconazole), which could result in a significant increase in peak plasma concentration and exposure to diclofenac due to inhibition of diclofenac metabolism.
Antidiabetics: Clinical studies have shown that diclofenac can be given together with oral antidiabetic agents without influencing their clinical effect. However, there have been isolated reports of both hypoglycaemic and hyperglycaemic effects necessitating changes in the dosage of the antidiabetic agents during treatment with diclofenac. Therefore, monitoring of the blood glucose level is recommended as a precautionary measure during concomitant therapy.
Inhibition of prostaglandin synthesis may adversely affect the pregnancy and/or the embryo/foetal development. Data from epidemiological studies suggest an increased risk of miscarriage and of cardiac malformation and gastroschisis after use of a prostaglandin synthesis inhibitor 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 death.
In addition, increased incidences of various malformations, including cardiovascular malformations, have been reported in animals given a prostaglandin synthesis inhibitor during the organogenetic period. During the first and second trimester of pregnancy, Motifene should not be given unless absolutely necessary. If Motifene is used by a woman when attempting to conceive, or during the first and second trimester of pregnancy, the dose and durations should be kept as low and as short as possible.
During the third trimester of pregnancy, all prostaglandin synthesis inhibitors may cause the following in the foetus:
In the mother and the neonate, at the end of pregnancy:
Consequently, Motifene is contraindicated during the third trimester of pregnancy.
In limited studies so far available, NSAIDs can appear in breast milk in very low concentrations. NSAIDs should, if possible, be avoided when breast-feeding.
See section 4.4 regarding female fertility.
Motifene has minor or moderate influence on the ability to drive and use machines. Undesirable effects such as dizziness, drowsiness, fatigue and visual disturbances, vertigo, somnolence or other central nervous system disturbances are possible after taking NSAIDs. If affected, patients should not drive or operate machinery.
If serious side-effects occur, Motifene should be withdrawn.
The most commonly reported adverse reactions are gastrointestinal in nature.
Adverse reactions from Motifene in clinical trials and epidemiological data are summarised in the table below.
The following terminologies have been used in order to classify the occurrence of adverse reactions: Very common (≥1/10), Common (≥1/100 to <1/10), Uncommon (≥1/1,000 to <1/100), Rare (≥1/10,000 to <1/1,000), Very rare (<1/10,000).
| MedDRA System Organ Class | Adverse reactions | Frequency |
|---|---|---|
| Blood and lymphatic system disorders | Leucopenia, neutropenia, thrombocytopenia, haemolytic anaemia, aplastic anaemia, agranulocytosis. | Very rare |
| Immune system disorders | Non-specific allergic reactions, anaphylactoid reactions (including hypotension and shock) and anaphylaxis. Respiratory tract reactivity comprising asthma, aggravated asthma, bronchospasm or dyspnoea. | Rare |
| Angioedema, angioneurotic oedema (including face oedema). | Very rare | |
| Psychiatric disorders | Depression, disorientation, insomnia, irritability, psychotic reactions, nightmares. | Very rare |
| Nervous system disorders | Headache, dizziness. | Common |
| Somnolence. | Rare | |
| Memory disturbance, paraesthesia, aseptic meningitis (especially in patients with existing auto-immune disorders, such as lupus erythematosus, mixed connective tissue disease) with symptoms such as stiff neck, headache, nausea, vomiting, fever or disorientation. Confusion, hallucinations, malaise, fatigue and drowsiness, taste disturbances, tremor, convulsions, anxiety, cerebrovascular accident. | Very rare | |
| Eye disorders | Visual disturbance (blurred vision), diplopia, optic neuritis. | Very rare |
| Ear and labyrinth disorders | Vertigo. | Common |
| Impaired hearing, tinnitus. | Very rare | |
| Cardiac disorders | Oedema. | Rare |
| Hypertension, vasculitis, palpitations, chest pain, cardiac failure. | Very rare | |
| Kounis syndrome | Not Known | |
| Vascular disorders | Small increased risk of arterial thrombotic events (for example myocardial infarction or stroke). | Very rare |
| Respiratory, thoracic and mediastinal disorders | Asthma (including dyspnoea). | Rare |
| Pneumonitis. | Very rare | |
| Gastrointestinal disorders | Nausea, vomiting, diarrhoea, dyspepsia, abdominal pain, flatulence, anorexia. | Common |
| Gastritis, haematemesis, haemorrhagic diarrhoea, melaena, gastrointestinal ulcer (with or without bleeding or perforation), peptic ulcers, perforation or GI bleeding, sometimes fatal, particularly in the older people. | Rare | |
| Exacerbation of colitis and Crohn’s disease, constipation, ulcerative stomatitis, glossitis, oesophageal disorder, diaphragm like intestinal strictures, pancreatitis. | Very rare | |
| Ischaemic colitis. | Frequency not known | |
| Hepatobiliary disorders | Increased transaminases. | Common |
| Jaundice, abnormal liver function, hepatitis (in isolated cases fulminant). | Rare | |
| Hepatic necrosis, hepatic failure. | Very rare | |
| Skin and subcutaneous tissue disorders | Rash | Common |
| Urticaria | Rare | |
| Photosensitivity, skin eruptions, Bullous eruptions, eczema, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis (Lyell’s syndrome), loss of hair, dermatitis exfoliative, purpura, allergic purpura, pruritus. | Very rare | |
| Renal and urinary disorders | Nephrotoxicity in various forms, including interstitial nephritis, proteinuria, renal papillary necrosis, nephrotic syndrome, acute renal failure, urinary abnormalities (e.g. haematuria). | Very rare |
Clinical trial and epidemiological data consistently point towards an increased risk of arterial thrombotic events (for example myocardial infarction or stroke) associated with the use of diclofenac, particularly at high dose (150mg daily) and in long term treatment. (see section 4.3 and 4.4 for Contraindications and Special warnings and special precautions for use).
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 at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.
None known.
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