Klaryvid 250 mg. 500 mg. FC tablets.

KLARYVID is indicated for the treatment of the following mild to moderate severe infections caused by susceptible organisms:

• Lower respiratory tract infections such as bronchitis and pneumonia.
• Upper respiratory tract infections such as pharyngitis and sinusitis.
• Mild to moderately severe acute otitis media due to S. pneumoniae, M. catarrhalis and H. influenza.
• Skin and soft tissue infections such as folliculitis, cellulitis or erysipelas.
• Eradication of Helicobacter pylori when used in combination with a proton pump inhibitor and another antibiotic to decrease recurrence of duodenal ulcer.

Posology

Adults and children older than 12 years: 250 mg twice daily. In more severe infections, the dosage may be increased to 500 mg twice daily.

Renal impairment: Creatinine clearance (<30 ml/min): Reduce dose by half i.e. 250 mg once daily or 250 twice daily for severe infections. Limit the duration of treatment to 14 days.

Eradication of H. pylori

Adults: 500 mg twice daily, in combination with an appropriate antibiotic and an acid lowering agent, for 7 to 10 days. The safety and efficacy of KLARYVID in combination with proton-pump inhibitors other than omeprazole has not been established.

Atypical mycobacterial infections (MAC) in HIV patients

Adults: 500 mg twice daily. Treatment of disseminated MAC infections in AIDS patients should continue as long as clinical and microbiological benefit is demonstrated. A decrease in efficacy has been noted in patients taking KLARYVID for more than 12 weeks. KLARYVID should be used in conjunction with other anti-mycobacterial agents.

KLARYVID may be taken with or without meals.

Paediatric population

Safety and efficacy in infants under 6 months of age has not been established. KLARYVID is not suitable for use in children less than 12 years of age.

Method of administration

Administration is by the oral route.

• Hypersensitivity to macrolide antibiotics or to any of the excipients listed in section 6.1.
• Concomitant administration of KLARYVID and ergot alkaloids (e.g. ergotamine or dihydroergotamine) is contraindicated, as this may result in ergot toxicity (see sections 4.4 and 4.5).
• Concomitant administration of KLARYVID and oral midazolam is contraindicated (see section 4.5).
• Concomitant administration of KLARYVID and lomitapide is contraindicated (see section 4.5).
• Concomitant administration of KLARYVID with astemizole, cisapride, domperidone, pimozide and terfenadine as this may result in QT prolongation and cardiac dysrhythmias including ventricular tachycardia, fibrillation and torsades de pointes (see section 4.5 and 4.5).
• KLARYVID should not be given to patients with history of QT prolongation (congenital or documented acquired QT prolongation) or ventricular cardiac arrhythmia, including torsades de pointes (see sections 4.4 and 4.5).
• Concomitant administration with ticagrelor or ranolazine is contraindicated.
• KLARYVID should not be used concomitantly with HMG-CoA reductase inhibitors (statins) that are extensively metabolized by CYP3A4, (lovastatin or simvastatin), due to the increased risk of myopathy, including rhabdomyolysis (see section 4.5).
• Concomitant administration of KLARYVID and atypical antipsychotics that are predominantly metabolised through the CYP3A4 pathway, for example quetiapine, cariprazine, and aripiprazole may result in an increase of the antipsychotics as a result of inhibition which may present a potential for serious adverse reactions.
• As with other strong CYP3A4 inhibitors, KLARYVID should not be used in patients taking colchicine (see sections 4.4 and 4.5).
• KLARYVID should not be given to patients with electrolyte disturbances (hypokalaemia or hypomagnesaemia, due to the risk of prolongation of the QT interval).
• KLARYVID should not be used in patients who suffer from severe hepatic failure in combination with renal impairment.
• Porphyria.

KLARYVID should be used with caution in:

• KLARYVID is principally metabolised by the liver. Therefore, caution should be exercised in administering this antibiotic to patients with impaired hepatic function.
• Caution should also be exercised when administering KLARYVID to patients with moderate to severe renal impairment (see section 4.2).
• Renal function impairment (severe) u2013 The elimination of KLARYVID is reduced in patients with renal function impairment, especially those with a creatinine clearance of < 30 ml/min. The dose of KLARYVID should be halved or the dosing interval doubled in patients with a creatinine clearance of < 30 ml/min.
• Hepatic dysfunction, including increased liver enzymes, and hepatocellular and/or cholestatic hepatitis, with or without jaundice, has been reported with clarithromycin. Treatment with KLARYVID should be discontinued if any signs of hepatic dysfunction develop. Hepatic dysfunction is usually reversible but may be severe. In rare instances, hepatic failure with fatal outcome has been reported, usually associated with other serious underlying diseases and/or concomitant medicines. Some patients may have had pre-existing hepatic disease or may have been taking other hepatotoxic medicines. Patients should be advised to stop treatment and contact their doctor if signs and symptoms of hepatic disease develop, such as anorexia, jaundice, dark urine, pruritus, or tender abdomen. Isolated cases of increased serum creatinine have been reported.
• Rifabutin and rifampicin u2013 May decrease serum concentration of KLARYVID by >50 %. Co-administration has been reported to cause a higher incidence of uveitis compared to rifabutin alone (see section 4.5).
• Theophylline u2013 The area under the plasma concentration-time curve is increased. Monitoring of theophylline serum concentrations is recommended (see section 4.5).
• Pseudomembranous colitis has been reported with nearly all antibacterial medicines, including macrolides, and may range in severity from mild to life-threatening. Clostridioides difficile - associated diarrhoea (CDAD) has been reported with use of nearly all antibacterial medicines including clarithromycin and may range in severity from mild diarrhoea to fatal colitis. Treatment with antibacterial medicines alters the normal flora of the colon, which may lead to overgrowth of C. difficile. CDAD must be considered in all patients who present with diarrhoea following antibiotic use. Careful medical history is necessary since CDAD has been reported to occur over two months after the administration of antibacterial medicines. Therefore, discontinuation of KLARYVID therapy should be considered regardless of the indication. Microbial testing should be performed and adequate treatment initiated. Medicines inhibiting peristalsis should be avoided.
• There have been reports of colchicine toxicity with concomitant use of clarithromycin and colchicine, especially in the elderly, some of which occurred in patients with renal insufficiency. Deaths have been reported in some such patients (see section 4.5). Concomitant administration of KLARYVID and colchicine is contraindicated (see section 4.3).
• Caution is advised regarding concomitant administration of KLARYVID and triazolobenzodiazepines, such as triazolam, and intravenous or oromucosal midazolam (see section 4.5).
• Cardiovascular Events: Prolongation of the QT interval, reflecting effects on cardiac repolarisation imparting a risk of developing cardiac dysrhythmia and torsades de pointes, have been seen in patients treated with macrolides including clarithromycin (see section 4.8). Due to increased risk of QT prolongation and ventricular dysrhythmias (including torsades de pointes), the use of KLARYVID is contraindicated: in patients taking any of astemizole, cisapride, domperidone, pimozide and terfenadine; in patients who have electrolyte disturbances such as hypomagnesaemia or hypokalaemia; and in patients with a history of QT prolongation or ventricular cardiac dysrhythmia (see section 4.3).
• Furthermore, KLARYVID should be used with caution in the following: Patients with coronary artery disease, severe cardiac insufficiency, conduction disturbances or clinically relevant bradycardia. Patients concomitantly taking other medicines associated with QT prolongation other than those which are contraindicated. Epidemiological studies investigating the risk of adverse cardiovascular outcomes with macrolides have shown variable results. Some observational studies have identified a rare short-term risk of dysrhythmia, myocardial infarction and cardiovascular mortality associated with macrolides including clarithromycin. Consideration of these findings should be balanced with treatment benefits when prescribing KLARYVID.
• Pneumonia: In view of the emerging resistance of Streptococcus pneumoniae to macrolides, it is important that sensitivity testing be performed when prescribing KLARYVID for community-acquired pneumonia. In hospital-acquired pneumonia, KLARYVID should be used in combination with additional appropriate antibiotics.
• Skin and soft tissue infections of mild to moderate severity: These infections are most often caused by Staphylococcus aureus and Streptococcus pyogenes, both of which may be resistant to macrolides. Therefore, it is important that sensitivity testing be performed. In cases where betau2013lactam antibiotics cannot be used (e.g. allergy), other antibiotics, such as clindamycin, may be the medicine of first choice. Currently, macrolides are only considered to play a role in some skin and soft tissue infections, such as those caused by Corynebacterium minutissimum, acne vulgaris, and erysipelas and in situations where penicillin treatment cannot be used.
• In the event of severe acute hypersensitivity reactions, such as anaphylaxis, severe cutaneous adverse reactions (SCAR) (e.g. Acute generalised exanthematous pustulosis (AGEP), Stevens-Johnson Syndrome, toxic epidermal necrolysis and drug rash with eosinophilia and systemic symptoms (DRESS)), KLARYVID therapy should be discontinued immediately and appropriate treatment should be urgently initiated.
• KLARYVID should be used with caution when administered concurrently with medications that induce the cytochrome CYP3A4 enzyme (see section 4.5).
• HMG-CoA Reductase Inhibitors (statins): Concomitant use of KLARYVID with lovastatin or simvastatin is contraindicated (see section 4.3). Caution should be exercised when prescribing KLARYVID with other statins. Rhabdomyolysis has been reported in patients taking clarithromycin and statins. Patients should be monitored for signs and symptoms of myopathy. In situations where the concomitant use of KLARYVID with statins cannot be avoided, it is recommended to prescribe the lowest registered dose of the statin. Use of a statin that is not dependent on CYP3A metabolism (e.g. fluvastatin) can be considered (see section 4.5).
• Oral hypoglycaemic medicines/Insulin: There have been less frequent reports of hypoglycaemia, some of which occurred in patients on concomitant oral hypoglycaemics (such as sulphonylureas) or insulin. Careful monitoring of glucose is recommended (see section 4.5).
• Oral anticoagulants: There is a risk of serious haemorrhage and significant elevations in International Normalized Ratio (INR) and prothrombin time when clarithromycin is co-administered with warfarin (see section 4.5). INR and prothrombin times should be frequently monitored while patients are receiving KLARYVID and oral anticoagulants concurrently. Caution should be exercised when KLARYVID is co-administered with direct acting oral anticoagulants such as dabigatran, rivaroxaban and apixaban, particularly to patients at high risk of bleeding (see section 4.5).
• Long-term use may, as with other antibiotics, result in colonisation with increased numbers of non-susceptible bacteria and fungi. If superinfections occur, appropriate therapy should be instituted.
• Cross-resistance between KLARYVID and other macrolides, lincomycin and clindamycin have been reported.
• Adverse effects in immunocompromised patients treated with higher doses of KLARYVID over long periods include nausea, vomiting, taste perversion, abdominal pain, diarrhoea, rash, flatulence, headache, hearing disturbance, AST and ALT elevations, elevated BUN levels and abnormally low white blood cell and platelet counts. Additional low-frequency events included dyspnoea, insomnia and dry mouth.

Concomitant use of KLARYVID with:

• Astemizole, cisapride, domperidone, pimozide and terfenadine: Elevated cisapride levels have been reported in patients receiving clarithromycin and cisapride concomitantly. This may result in QT prolongation and cardiac dysrhythmias including ventricular tachycardia, ventricular fibrillation and torsades de pointes. Similar effects have been observed in patients taking clarithromycin and pimozide concomitantly (see section 4.3).
• Macrolides have been reported to alter the metabolism of terfenadine resulting in increased levels of terfenadine which has occasionally been associated with cardiac dysrhythmias, such as QT prolongation, ventricular tachycardia, ventricular fibrillation and torsades de pointes (see section 4.3). The concomitant administration of clarithromycin and terfenadine resulted in 2- to 3-fold increase in the serum level of the acid metabolite of terfenadine and in prolongation of the QT interval which did not lead to any clinically detectable effect. Similar effects have been observed with concomitant administration of astemizole and other macrolides.
• Ergot alkaloids: Co-administration of clarithromycin with ergotamine or dihydroergotamine has been associated with acute ergot toxicity characterized by vasospasm, and ischaemia of the extremities and other tissues including the central nervous system. Concomitant administration of KLARYVID and ergot alkaloids is contraindicated (see section 4.3).
• Oral Midazolam: When midazolam was co-administered with clarithromycin tablets (500 mg twice daily), midazolam AUC was increased 7-fold after oral administration of midazolam. Concomitant administration of oral midazolam and KLARYVID is contraindicated (see section 4.3).
• HMG-CoA Reductase Inhibitors (statins): Concomitant use of KLARYVID with lovastatin or simvastatin is contraindicated (see section 4.3) as these statins are extensively metabolized by CYP3A4 and concomitant treatment with KLARYVID increases their plasma concentration, which increases the risk of myopathy, including rhabdomyolysis. Reports of rhabdomyolysis have been received for patients taking clarithromycin concomitantly with these statins. If treatment with KLARYVID cannot be avoided, therapy with lovastatin or simvastatin must be suspended during the course of treatment. Caution should be exercised when prescribing KLARYVID with statins. In situations where the concomitant use of KLARYVID with statins cannot be avoided, it is recommended to prescribe the lowest registered dose of the statin. Use of a statin that is not dependent on CYP3A metabolism (e.g. fluvastatin) can be considered.
• Effects of other medicines on KLARYVID: Medicines that are inducers of CYP3A (e.g. rifampicin, phenytoin, carbamazepine, phenobarbital, St John's wort) may induce the metabolism of clarithromycin. This may result in sub-therapeutic levels of clarithromycin leading to reduced efficacy. Furthermore, it might be necessary to monitor the plasma levels of the CYP3A inducer, which could be increased owing to the inhibition of CYP3A by clarithromycin (see also the relevant product information for the CYP3A4 inducer administered). Concomitant administration of rifabutin and clarithromycin resulted in an increase in rifabutin and decrease in clarithromycin serum levels together with an increased risk of uveitis.
• The following medicines are known or suspected to affect circulating concentrations of clarithromycin; KLARYVID dosage adjustment or consideration of alternative treatments may be required: Efavirenz, nevirapine, rifampicin, rifabutin and rifapentine: Strong inducers of the cytochrome P450 metabolism system such as efavirenz, nevirapine, rifampicin, rifabutin, and rifapentine may accelerate the metabolism of KLARYVID and thus lower the plasma levels of clarithromycin, while increasing those of 14-OH-clarithromycin, a metabolite that is also microbiologically active. Since the microbiological activities of clarithromycin and 14-OH-clarithromycin are different for different bacteria, the intended therapeutic effect could be impaired during concomitant administration of KLARYVID and enzyme inducers.
• Etravirine: Clarithromycin exposure was decreased by etravirine; however, concentrations of the active metabolite, 14-OH- clarithromycin, were increased. Because 14-OH-clarithromycin has reduced activity against Mycobacterium avium complex (MAC), overall activity against this pathogen may be altered; therefore, alternatives to KLARYVID should be considered for the treatment of MAC.
• Fluconazole: Concomitant administration of fluconazole 200 mg daily and clarithromycin 500 mg twice daily led to increases in the mean steady-state minimum clarithromycin concentration (C min) and area under the curve (AUC) of 33 % and 18 % respectively. Steady state concentrations of the active metabolite 14-OH-clarithromycin were not significantly affected by concomitant administration of fluconazole. No KLARYVID dose adjustment is necessary.
• Ritonavir: Marked inhibition of the metabolism of clarithromycin has been demonstrated during concomitant administration of ritonavir 200 mg every 8 hours and clarithromycin 500 mg every 12 hours. The clarithromycin C max increased by 31 %, C min increased 182 % and AUC increased by 77 % with concomitant administration of ritonavir. An essentially complete inhibition of the formation of 14-OH-clarithromycin was noted. Because of the large therapeutic window for clarithromycin, no dosage reduction should be necessary in patients with normal renal function. However, for patients with renal impairment, the following dosage adjustments should be considered: For patients with CLCR 30 to 60 ml/min the dose of KLARYVID should be reduced by 50 %. For patients with CLCR < 30 ml/min the dose of KLARYVID should be decreased by 75 %. Doses of KLARYVID greater than 1 g/day should not be co-administered with ritonavir.
• Similar dose adjustments should be considered in patients with reduced renal function when ritonavir is used as a pharmacokinetic enhancer with other HIV protease inhibitors including atazanavir and saquinavir (see section below, Bi-directional medicine interactions).

The safety of KLARYVID for use during pregnancy has not been established. Based on variable results obtained from animal studies and experience in humans, the possibility of adverse effects on embryofoetal development cannot be excluded. Some observational studies evaluating exposure to clarithromycin during the first and second trimester have reported an increased risk of miscarriage compared to no antibiotic use or other antibiotic use during the same period.

The available epidemiological studies on the risk of major congenital malformations with use of macrolides including clarithromycin during pregnancy provide conflicting results.

Breastfeeding

The safety of KLARYVID for using during breastfeeding of infants has not been established. KLARYVID is excreted into human breast milk in small amounts. It has been estimated that an exclusively breastfed infant would receive about 1,7 % of the maternal weight-adjusted dose of clarithromycin.

Fertility

In the rat, fertility studies have not shown any evidence of harmful effects.

There are no data on the effect of KLARYVID on the ability to drive or use machines. The potential for dizziness, vertigo, confusion and disorientation should be taken into account before patients on KLARYVID drive or use machinery.

Table 1: Tabulated list of adverse reactions

System organ class

• Frequent
• Less frequent
• Frequency not known*

Infections and infestations

• Cellulitis 1, candidiasis, gastroenteritis 2, infection 3, vaginal infection.
• Pseudomembranous colitis, erysipelas.

Blood and lymphatic system disorders

• Leucopoenia, neutropenia 4, thrombocythaemia 3, eosinophilia 4.
• Agranulocytosis, thrombocytopenia.

Immune system disorders

• Hypersensitivity reactions, Anaphylactoid reaction, angioedema.
• anaphylaxis anaphylactoid reaction 1.

Metabolism and nutrition disorders

• Anorexia, decreased appetite.

Psychiatric disorders

• Insomnia.
• Anxiety, nervousness 3.
• Psychotic disorder, confusional state 5, depersonalisation, depression, disorientation, hallucination, abnormal dreams, mania.

Nervous system disorders

• Dysgeusia, headache.
• Loss of consciousness 1, dyskinesia 1, dizziness, somnolence 5, tremor.
• Convulsions, ageusia, parosmia, anosmia, paraesthesia.

Ear and labyrinth disorders

• Vertigo, tinnitus, impaired hearing.
• Deafness.

Cardiac disorders

• Cardiac arrest 1, atrial fibrillation 1, electrocardiogram QT prolonged, extrasystoles 1, palpitations.
• Ventricular fibrillation, torsades de pointes, ventricular tachycardia.

Vascular disorders

• Vasodilation 1.
• Haemorrhage.

Respiratory, thoracic and mediastinal disorders

• Asthma 1, epistaxis 2, pulmonary embolism 1.

Gastrointestinal disorders

• Nausea, vomiting, abdominal pain, diarrhoea, dyspepsia.
• Oesophagitis 1, gastroesophageal reflux disease 2, gastritis, proctalgia 2, glossitis, stomatitis, abdominal distension 4, constipation, dry mouth, eructation, flatulence.
• Tongue discolouration, tooth discolouration, pancreatitis acute.

Hepato-biliary disorders

• Abnormal liver function test.
• Cholestasis 4, hepatitis 4, increased alanine aminotransferase, increased aspartate aminotransferase, increased gamma glutamyltransferase 4.
• Hepatic failure, jaundice hepatocellular.

Skin disorders

• Rash, hyperhidrosis.
• Dermatitis bullous 1, pruritus, rash maculo-papular 3, Stevens-Johnson syndrome, toxic epidermal necrolysis, severe cutaneous adverse reactions (SCAR) (e.g. acute generalised exanthematous pustulosis (AGEP), drug rash with eosinophilia and systemic symptoms (DRESS), acne.

Musculoskeletal and connective tissue disorders

• Muscle spasms 3, musculoskeletal stiffness 1, myalgia 2.
• Rhabdomyolysis 2,6, myopathy.

Renal and urinary disorders

• Increased blood creatinine 1, increased blood urea 1.
• Nephritis interstitial, renal failure.

General disorders

• Injection site phlebitis 1, injection site pain 1, injection site inflammation 1.
• Malaise 4, pyrexia 3, asthenia, chest pain 4, chills 4, fatigue 4.

Investigations

• Albumin globulin ratio abnormal 1, increased blood alkaline phosphatase 4, Increased international normalised ratio, prothrombin time prolonged, abnormal urine colour.

* Undesirable effects reported only for the powder for solution for injection formulation. Undesirable effects reported only for the extended-release tablets formulation. Undesirable effects reported only for the granules for oral suspension formulation. Undesirable effects reported only for the immediate-release tablets formulation. see Description of selected adverse reactions.

(See section 4.4)

Symptoms of overdose: Ingestion of large amounts of KLARYVID can be expected to produce gastrointestinal symptoms. Adverse reactions accompanying overdosage should be treated by the prompt elimination of unabsorbed medicine and supportive measures. Altered mental status, paranoid behaviour, hypokalaemia and hypoxaemia may occur.

Treatment of overdose: Treatment is symptomatic and supportive. KLARYVID is not expected to be appreciably affected by haemodialysis or dialysis.