TENSOPYN Tablet Ref.[51217] Active ingredients: Caffeine Codeine Doxylamine Paracetamol

Source: Health Products Regulatory Authority (ZA)  Revision Year: 2023  Publisher: CIPLA MEDPRO (PTY) LTD., Building 9, Parc du Cap, Mispel Street, Bellville, 7530

4.3. Contraindications

TENSOPYN is contraindicated in the following:

  • In patients with a known hypersensitivity to paracetamol, codeine phosphate, caffeine and doxylamine succinate or to any of the excipients used in the formulation of TENSOPYN (see section 6.1).
  • severe liver or kidney function impairment,
  • acute intermittent porphyria,
  • respiratory depression especially in the presence of cyanosis and excessive bronchial secretion, after operation on the biliary tract, acute alcoholism,
  • head injuries and conditions in which intracranial pressure is raised.
  • It should not be given during an attack of bronchial asthma or in heart failure secondary to chronic lung disease.
  • in patients taking monoamine oxidase inhibitors or within 14 days of stopping such treatment,
  • After an operation on the biliary tract.
  • Acute alcoholism (see section 4.4).
  • In patients for whom it is known that they are CYP2D6 ultra-rapid metabolisers (see section 4.4 and 4.6).
  • Safety in pregnancy and lactation has not been established.

4.4. Special warnings and precautions for use

This product contains paracetamol which may be fatal in overdose. In the eventof overdosage or suspected overdose and not withstanding the fact that the person may be asymptomatic, the nearest doctor, hospital or Poison Centre must be contacted immediately.

Do not take continuously for more than 5 days without consulting a doctor. Also consult your doctor if no relief is obtained with the recommended dosage.

Do not take concurrently with any other paracetamol or codeine containing medicine. TENSOPYN tablets may lead to drowsiness and impaired concentration, which may be aggravated by the simultaneous intake of alcohol or other central nervous system depressant agents. Patients should be warned against taking charge of vehicles or machinery or performing potentially hazardous tasks where loss of concentration may lead to accidents.

Dosage in excess of that recommended may cause severe liver damage.

Care is advised in the administration of this preparation to patients with impaired kidney or liver function and in those with hypertension, hypothyroidism, adrenocortical insufficiency, prostatic hypertrophy, urinary retention, susceptibility to angle-closure glaucoma, shock, obstructive bowel disorders, acute abdominal conditions (e.g. peptic ulcer), recent gastrointestinal surgery, gallstones, myasthenia gravis, a history of cardiac arrhythmias or convulsions, hyperthyroidism, hepatic dysfunction, acute febrile illness, asthma, impaired kidney and liver function, hypotension, elderly, and in patients with a history of drug abuse or emotional instability.

Codeine may induce faecal impaction, producing incontinence, spurious diarrhoea, abdominal pain and rarely colonic obstruction. Elderly patients may metabolise or eliminate opioid analgesics more slowly than younger adults.

The dosage in renal functional impairment must be reduced. Use with caution in renal disease. Should be taken with caution by asthmatics.

Exceeding the prescribed dose, together with prolonged and continuous use of this medication, may lead to dependency and addiction.

Care should be taken when administering this preparation during the first trimester of pregnancy. It should be given with care to patients with alcohol dependence, chronic malnutrition, or dehydration.

Administration of pethidine and possibly other opioid analgesics to patients taking a monoamine oxidase inhibitor (MAOI) has been associated with very severe and sometimes fatal reactions. See also section 4.3 regarding contraindication of taking TENSOPYN with MAOIs because of the doxylamine component.

Risks from concomitant use of opioids and benzodiazepines

Concomitant use of opioids, including codeine, and sedative medicines such as benzodiazepines or related drugs may result in sedation, respiratory depression, coma, and death. Because of these risks, concomitant prescribing of sedative medicines, such as benzodiazepines or related drugs, with opioids should be reserved for patients for whom alternative treatment options are not possible.

If a decision is made to prescribe codeine concomitantly with sedative medicines such as benzodiazepines, the lowest effective dose should be used, and the duration of treatment should be as short as possible. The patients should be followed closely for signs and symptoms of respiratory depression and sedation. In this respect, it is strongly recommended to inform patients and their environment to be aware of these symptoms (see section 4.5).

Risks from concomitant use of opioids and alcohol

Concomitant use of opioids, including codeine, with alcohol may result in sedation, respiratory depression, coma and death. Concomitant use with alcohol is not recommended (see section 4.5).

The hazards of overdose are greater in those with non-cirrhotic alcoholic liver diseases.

CY2D6 metabolism

Codeine is metabolised by the liver into morphine, its active metabolite. If a patient has a deficiency or is completely lacking this enzyme an adequate analgesic effect will not be obtained. However, if the patient is an extensive or ultra-rapid metaboliser there is an increased risk of developing side effects of opioid toxicity even at commonly prescribed doses. These patients convert codeine into morphine rapidly resulting in higher than expected serum morphine levels.

General symptoms of opioid toxicity include confusion, somnolence, shallow breathing, small pupils, nausea, vomiting, constipation and lack of appetite. In severe cases this may include symptoms of circulatory and respiratory depression, which may be life-threatening and very rarely fatal.

Paediatric population

Not recommended for children under 12 years of age.

Overdosage is very dangerous in young children.

4.5. Interaction with other medicinal products and other forms of interaction

The speed of absorption of paracetamol may be increased by metoclopramide, domperidone and absorption reduced by cholestyramine.

The anticoagulant effect of warfarin and other coumarins may be enhanced by prolonged regular daily use of paracetamol with increased risk of bleeding; occasional doses have no significant effect.

TENSOPYN may enhance the sedative effects of CNS depressants such as alcohol, barbiturates, anaesthetics, hypnotics, other opioid analgesics, anxiolytic sedatives, antipsychotics, tricyclic antidepressants and phenothiazines, resulting in increased CNS depression. It may also have an additive antimuscarinic action with other drugs, such as atropine and some antidepressants.

Benzodiazepines

The concomitant use of opioids with sedative medicines such as benzodiazepines or related drugs increases the risk of sedation, respiratory depression, coma and death because of additive CNS depressant effect. The dosage and duration of concomitant use should be limited (see section 4.4).

Alcohol and opioids

The concomitant use of alcohol and opioids increases the risk of sedation, respiratory depression, coma, and death because of additive CNS depressant effect. Concomitant use with alcohol is not recommended (see section 4.4).

The hypotensive actions of diuretics and anti-hypertensive agents may be potentiated when used concurrently with opioid analgesics. Concurrent use of hydroxyzine with codeine may result in increased analgesia as well as increased CNS depressant and hypotensive effects.

The respiratory depressant effect caused by neuromuscular blocking agents may be additive to the central respiratory depressant effects of opioid analgesics. Quinidine can inhibit the analgesic effect of codeine.

Concurrent use of codeine with antidiarrhoeal and antiperistaltic agents such as loperamide and kaolin may increase the risk of severe constipation. Concomitant use of antimuscarinics or medications with antimuscarinic action may result in an increased risk of severe constipation which may lead to paralytic ileus and/or urinary retention.

Codeine may delay the absorption of mexiletine and thus reduce the antiarrhythmic effect of the latter. Codeine may antagonise the gastrointestinal effects of metoclopramide, cisapride and domperidone. Cimetidine inhibits the metabolism of opioid analgesics resulting in increased plasma concentrations.

Naxolone antagonises the analgesic, CNS and respiratory depressant effects of opioid analgesics. Naltrexone also blocks the therapeutic effect of opioids.

Doxylamine: Monamine oxidase inhibitors (MAOIs) or within 14 days of stopping treatment with these products as there is a risk of serotonin syndrome (see section 4.3 and 4.4).

Concomitant administration of pethidine and possibly other opioid analgesics to patients taking MAOIs has been associated with very severe and sometimes fatal reactions such as severe CNS excitation or depression, including hypertension or hypotension.

Although this has not been documented with codeine, it is possible that a similar interaction May occur and therefore the use of codeine should be avoided while the patient is taking MAOIs and for 2 weeks after MAOI discontinuation.

Incompatibilities: Codeine has been reported to be incompatible with phenobarbitone sodium forming a codeine-phenobarbitone complex, and with potassium-iodide, forming crystals of codeine periodide. Acetylation of codeine phosphate by aspirin has occurred in solid dosage forms containing the two medicines, even at low moisture levels.

Interference with laboratory tests: Opioid analgesics interfere with a number of laboratory tests including plasma amylase, lipase, bilirubin, alkaline phosphatase, lactate dehydrogenase, alanine aminotransferase and aspartate aminotransferase. Opioids may also interfere with gastric emptying studies as they delay gastric emptying and with hepatobiliary imaging using technetium Tc 99m disofenin as opioid treatment may cause constriction of the sphincter of Oddi and increase biliary tract pressure.

The metabolism of paracetamol is possibly accelerated by carbamazepine, phenytoin, phenobarbital, primidone (also there have been isolated reports of hepatotoxicity).

4.6. Pregnancy and lactation

Pregnancy

Reported epidemiological studies in human pregnancy have shown no ill effects due to paracetamol used in the recommended dosage, but patients should follow the advice of their doctor regarding its use.

A large amount of data on pregnant women indicate neither malformative, nor feto/neonatal toxicity. Reported epidemiological studies on neurodevelopment in children exposed to paracetamol in utero show inconclusive results. If clinically needed, paracetamol can be

used during pregnancy however it should be used at the lowest effective dose for the shortest possible time and at the lowest possible frequency.

Codeine crosses the placenta. There is no adequate evidence of safety in human pregnancy and a possible association with respiratory and cardiac malformations has been reported. Regular use during pregnancy may cause physical dependence in the foetus leading to withdrawal symptoms in the neonate. Use during pregnancy should be avoided if possible.

Use of opioid analgesia during labour may cause respiratory depression in the neonate, especially the premature neonate. These medicines should not be given during the delivery of a premature baby.

Breastfeeding

Paracetamol is excreted in breast milk but not in a clinically significant amount.

Codeine should not be used during breastfeeding.

At normal therapeutic doses codeine and its active metabolites may be present in breast milk at very low doses and is unlikely to adversely affect the breast fed infant. However, if the patient is an ultra-rapid metaboliser of CYP2D6, higher levels of the active metabolites may be present in breast milk and on very rare occasions may result in symptoms of opioid toxicity in the infant, which may be fatal (see section 4.3 and 4.4).

4.7. Effects on ability to drive and use machines

The use of TENSOPYN may lead to drowsiness and impaired concentration that may be aggravated by the simultaneous intake of alcohol or other central nervous system depressants. Patients should be advised, particularly at the initiation of therapy, against taking charge of vehicles or machinery or performing potentially hazardous tasks where loss of concentration could lead to accidents.

4.8. Undesirable effects

Tabulated summary of adverse reactions

The following adverse reactions have been classified according to the following categories, frequent, less frequent and frequency unknown.

MedDRA system organ Class Frequency Side effects
Blood and lymphatic system
disorders
Less frequent Haematological reactions including
thrombocytopenia, leucopenia,
pancytopenia, neutropenia,
agranulocytosis, thrombocytopenic
purpura, unusual bleeding or
bruising, blood discrasias, including
agranulocytosis, eosinophilia, and
haemolytical anaemia.
Immune system disorders Less frequent Sensitivity reactions
Frequency
unknown
Hypersensitivity, anaphylaxis,
bronchospasms, angioedema.
Metabolism and nutrition
disorders
Frequency
unknown
Dry mouth
Endocrine disorders Frequency
unknown
Pancreatitis
Psychiatric disorders Frequent Drowsiness, confusion.
Less frequent Excitement, feelings of unreality,
mental depression, sedation,
lassitude, deepening coma,
irritability, nightmares, anorexia,
nervousness.
Frequency
unknown
Psychomotor impairment,
extrapyramidal effects, sleep
disturbances, insomnia,
restlessness, changes in mood,
euphoria, decreased libido,
hallucinations.
Nervous system disorders Frequent CNS depression
Less frequent Confusion, dry mouth, sweating,
facial flushing, faintness, sedation,
vertigo.
Frequency
unknown
Slight drowsiness to deep sleep,
lassitude, dizziness, incoordination
(although paradoxical stimulation
may occasionally occur, especially
in children), headache,
photosensitivity, convulsions,
paraesthesias, tremor depression,
CNS stimulation, anxiety,
restlessness, tremor, raised
intracranial pressure
Eye disorders Less frequent Scintillating scotoma
Frequency
unknown
Blurred vision, miosis.
Ear and labyrinth disorders Frequency
unknown
Tinnitus, vertigo
Cardiac disorders Less frequent Fast, slow, or pounding heartbeat,
extrasystole, angioedema.
Frequency
unknown
Palpitations, arrhythmias,
hypotension (including orthostatic
hypotension), bradycardia,
tachcardia.
Vascular disorders Less frequent Swelling of face, hypotension,
hypertension, orthostatic
hypotension, circulatory failure,
hyperthermia, paraesthesia.
Respiratory, thoracic and
mediastinal disorders
Less frequentIncreased sweating, irregular
breathing, shortness of breath,
wheezing or troubled breathing,
respiratory depression, tightness of
the chest, bronchospasm.
Frequency
unknown
Thickened respiratory-tract
secretions
Gastrointestinal disorders Frequent Constipation, nausea and vomiting
Less frequentDiarrhoea, gastric ulceration,
gastro-intestinal disturbances, colic,
epigastric pain, bloody or black,
tarry stools, sore throat, increased
gastric reflux, abdominal pain.
Hepato-biliary disorders Less frequent Biliary spasms
Frequency
unknown
Jaundice
Skin and subcutaneous tissue
disorders
Less frequent Rashes, skin eruptions, urticaria,
pruritus, purpura, yellow eyes or
skin, pinpoint red spots on skin,
allergic reactions, hives or itching,
sores, ulcers, or white spots on lips
or in the mouth, skin rash. This rash
is usually erythromatous or
urticarial, but sometimes more
serious and may be accompanied
by drug fever and mucosal lesions.
Redness or flushing of face.
Musculoskeletal, connective
tissue and bone disorders
Less frequent Trembling or uncontrolled muscle
movements or muscle rigidity,
muscular weakness and
incoordination, weakness of the
hands.
Frequency
unknown
Myalgia.
Renal and urinary disorders Less frequent Bloody or cloudy urine, sudden
decrease in amount of urine
Frequency
unknown
Urinay difficulty or retention, difficult
micturition, ureteric or biliary
spasms, antidiuretic effect.
Reproductive system and breast
disorders
Frequency
unknown
Decreased potency.
General disorders and
administrative site conditions
Less frequent Unusual tiredness or weakness,
headache, raised intracranial
pressure
Frequency
unknown
Fever, sweating, hair loss, facial
flushing, hypothermia

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicine is important. It allows continued monitoring of the benefit/risk balance of the medicine. Health care providers are asked to report any suspected adverse reactions to SAHPRA via the “6.04 Adverse Drug Reactions Reporting Form”, found online under SAHPRA’s publications: https://www.sahpra.org.za/Publications/Index/8 and to Cipla Medpro (Pty) Ltd at drugsafetysa@cipla.com or telephone 080 222 6662 (toll free).

6.2. Incompatibilities

Not applicable.

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