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methscopolamine nitrate and
phenylephrine hydrochloride tablet, chewable
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----------Dallergy Chewable Tablets
Each Dallergy Chewable Tablet (capsule shaped tablet) contains:
Chlorpheniramine Maleate . . . . . . . . . . . 2 mg
Methscopolamine Nitrate . . . . . . . . . . 1.25 mg
Phenylephrine Hydrochloride . . . . . . . . 10 mg
Chlorpheniramine Maleate is an antihistamine having the chemical name 2-pyridinepropanamine, γ-(4 chlorophenyl)- N,N-dimethyl, (Z)-2- butenedioate (1:1), having the following structural formula:
C16H19ClN2 • C4H4O4 M.W. 390.86
Methscopolamine Nitrate is an anticholinergic having the chemical name 3-Oxa-9-azoniatricyclo [3.3.1.02,4]nonane, 7-(3-hydroxy-1-oxo-2-phenylpropoxy)- 9, 9- dimethyl-, nitrate, [7(S)-(1α, 2β, 4β, 5α, 7β)]-, having the following structural formula:
C18H24NO4• NO3 M.W. 380.4
Phenylephrine Hydrochloride is a decongestant having the chemical name Benzenemethanol, 3-hydroxy-α- [(methylamino)methyl]-, hydrochloride (R)-, having the following structural formula:
C9H13NO2 • HCl M.W. 203.67
Dallergy Chewable Tablets contain ingredients of the following therapeutic classes: antihistamine, antisecretory agent and nasal decongestant.
acacia, compressible sugar, D&C Red #30, FD&C Blue #1, grape flavor, magnesium stearate (veg.), mannitol, methylcellulose, povidone and saccharin sodium.
Chlorpheniramine maleate competitively antagonizes most of the smooth muscle stimulating actions of histamine on the H1 receptors of the GI tract, uterus, large blood vessels, and bronchial muscle. It also antagonizes the action of histamine that results in increased capillary permeability and the formation of edema. Chlorpheniramine maleate is an alkylamine- type antihistamine. This group of antihistamines is among the most active histamine antagonists and is generally effective in relatively low doses. They thereby prevent, but do not reverse, responses mediated by histamine alone. The anticholinergic actions of most antihistamines provide a drying effect on the nasal mucosa. These drugs are not so prone to produce drowsiness and are among the most suitable agents for daytime use, but a significant proportion of patients do experience this effect.
Methscopolamine nitrate is one of the principal anticholinergic/antispasmodic components of the belladonna alkaloids that exhibit antisecretory activity. Methscopolamine inhibits the muscarinic actions of acetylcholine on structures innervated by postganglionic cholinergic nerves: smooth muscle, cardiac muscle, sinoatrial and atrioventricular nodes, and exocrine glands. In general, the smaller doses of anticholinergics inhibit salivary and bronchial secretions, sweating, and accommodation; cause dilation of the pupil; and increase the heart rate.
Phenylephrine hydrochloride is a sympathomimetic amine, which acts directly on α-adrenergic receptors in the mucosa of the respiratory tract to produce vasoconstriction that increases peripheral resistance, resulting in an increase in both systolic and diastolic blood pressure. Accompanying the pressor response is a marked reflex bradycardia due to increased vagal activity. It produces vasoconstriction that lasts longer than that produced by ephedrine and epinephrine, and in therapeutic doses, produces little or no central nervous system (CNS) stimulation. Phenylephrine has reduced bioavailability from the gastrointestinal tract because of first pass metabolism by monoamine oxidase in the stomach and liver.
INDICATIONS AND USAGE
This product provides relief of the symptoms resulting from irritation of sinus, nasal, and upper respiratory tract tissue. Phenylephrine exerts a vasoconstrictive and decongestive action while chlorpheniramine maleate decreases the symptoms of watering eyes, post nasal drip, and sneezing. Methscopolamine nitrate further augments the antisecretory activity of this product.
This product is contraindicated in women who are pregnant or nursing. This product is contraindicated in children under six years of age, because this age group is sensitive to the effects of sympathomimetic amines. It is also contraindicated in newborn or premature infants, because this age group has an increased susceptibility to the anticholinergic side effects of chlorpheniramine maleate. Geriatric patients may be more sensitive to the effects of this medication.
Risk-benefit should be considered when the following conditions exist: Sensitivity to phenylephrine, chlorpheniramine or methscopolamine; Asthma, acute; Bladder neck obstruction; Brain damage, in children; Cardiac disease, especially cardiac arrhythmias, congestive heart failure, coronary artery disease, and mitral stenosis; Cardiovascular disease; Diabetes mellitus; Down’s Syndrome; Esophagitis, reflux; Glaucoma; Hemorrhage, acute, with unstable cardiovascular status; Hepatic function impairment; Hernia; Hypertension; Hyperthyroidism; Intestinal atony in the elderly or debilitated patient; Lung disease, chronic; Myasthenia gravis; Neuropathy, autonomic; Paralytic ileus; Prostatic hypertrophy; Psychosis or other psychiatric disorders; Pyloric obstruction; Renal function impairment; Spastic paralysis, in children; Tachycardia; Toxemia of pregnancy; Ulcerative colitis; Urinary retention, or predisposition to; Uropathy; Xerostomia.
This product may cause drowsiness or blurred vision. Patients taking this product should be warned not to engage in activities requiring mental alertness such as operating a motor vehicle or other machinery, or to perform hazardous tasks while taking this drug. Sympathomimetic amines should be used with caution in patients with hypertension, ischemic heart disease, diabetes mellitus, increased intraocular pressure, hyperthyroidism, or prostatic hypertrophy. Sympathomimetic amines in overdosage may produce CNS stimulation with convulsions or cardiovascular collapse with accompanying hypotension. Do not exceed recommended dosage.
Antihistamines should be used with considerable caution in pyloroduodenal obstruction; symptomatic prostatic hypertrophy; bladder neck obstruction. Antihistamines may cause excitability, especially in children. At dosages higher than the recommended dose, nervousness, dizziness or sleeplessness may occur. Do not exceed recommended dosage.
Heat prostration can occur with methscopolamine used where the environmental temperature is high. Diarrhea may be an early symptom of incomplete intestinal obstruction, especially in patients with ileostomy or colostomy; in this instance, use of methscopolamine would be inappropriate and possibly harmful.
Use phenylephrine with caution in patients with hypoxia, acidosis, or a history of arteriosclerosis, bradycardia, partial heart block, hypertension, myocardial disease, thrombosis, or ventricular tachycardia. Antihistamines have an atropine-like action and should be used with caution in patients with a history of bronchial asthma, emphysema, increased intraocular pressure, hyperthyroidism, cardiovascular disease and hypertension. Use methscopolamine with caution in patients with hiatal hernia associated with reflux esophagitis. Use extreme caution and only when needed in patients with autonomic neuropathy, hyperthyroidism, coronary heart disease, congestive heart failure, and cardiac arrhythmia. Investigate any tachycardia before giving any anticholinergic drugs since they may increase the heart rate. Prolonged use of anticholinergics may decrease or inhibit salivary flow, thus contributing to the development of caries, periodontal disease, oral candidiasis, and discomfort.
Information for Patients
Patient consultation should include the following information regarding proper use of this medication:
• Do not take more medication than the amount recommended.
• This medication should be taken 30 minutes to one hour before meals.
• Take medication with food, water, or milk to minimize gastric irritation.
• This medication should be used with caution during exercise or hot weather; overheating may result in heat stroke.
• Do not drive or operate machinery if drowsiness or dizziness occurs.
• Do not ingest alcoholic beverages, monoamine oxidase (MAO) inhibitors, or CNS depression-producing medications (hypnotics, sedatives, tranquilizers) while taking this medication.
• This medication possibly increases sensitivity of eyes to light.
• Methscopolamine nitrate may cause blurred vision. Patients should observe caution before driving, using machinery or performing other tasks requiring visual alertness.
• If a dose is missed, the medication should be taken as soon as possible unless it is almost time for the next dose: not doubling doses.
• This medication should be stored in a tight, light-resistant container at temperatures between 20°-25°C (68°- 77°F).
• Keep all medications out of the reach of children. In case of accidental overdose, seek professional assistance or contact a poison control center immediately.
Caution patients about the signs of potential side effects, especially:
• Anticholinergic effects – clumsiness or unsteadiness; severe drowsiness; severe dryness of mouth, nose, or throat; flushing or redness of face; shortness of breath or troubled breathing.
• Blood dyscrasias - sore throat and fever; unusual bleeding or bruising; unusual tiredness or weakness.
• Fast or irregular heartbeat.
• Psychotic episodes.
• Tightness in chest.
Note: When anticholinergics are given to patients, especially children, where the environmental temperature is high, there is risk of rapid increase in body temperature because of suppression of sweat gland activity.
Infants, patients with Down’s syndrome, and children with spastic paralysis or brain damage may show an increased response to anticholinergics, thus increasing the potential for side effects. Geriatric or debilitated patients may respond to usual doses of anticholinergics with excitement, agitation, drowsiness, or confusion.
The following may be especially important in patient monitoring (other tests may be warranted in some patients, depending on conditions): Blood pressure determination – recommended at frequent intervals during therapy; Electrocardiogram (ECG) - monitoring may be required; Intraocular pressure determination – recommended at periodic intervals, as these medications may increase the intraocular pressure by producing mydriasis.
Do not take this product if you are presently taking, or have taken within the preceding two weeks, a prescription drug for high blood pressure or depression without first consulting your physician. Absorption of other oral medications may be decreased during concurrent use with anticholinergics due to decreased gastrointestinal motility and delayed gastric emptying. Combinations containing any of the following medications, depending on the amount present, may also interact with this product:
• Alkalizers, such as: calcium- and/or magnesium containing antacids; Carbonic anhydrase inhibitors; citrates; sodium bicarbonate - urinary excretion of anticholinergics may be delayed by alkalization of the urine, thus potentiating methscopolamine’s therapeutic and/or side effects.
• α-adrenergic blocking agents or other medications with α-adrenergic blocking action - prior administration of α-adrenergic blocking agents may block the pressor response to phenylephrine, possibly resulting in severe hypotension; medications with α-adrenergic blocking action may decrease the pressor effect and shorten the duration of action of phenylephrine.
• Antacids or adsorbent antidiarrheals - simultaneous use of these medications may reduce absorption of methscopolamine, resulting in decreased therapeutic effectiveness; doses of these medications should be spaced 2 or 3 hours apart from doses of methscopolamine.
• Anesthetics, hydrocarbon inhalation - Concurrent use of chloroform, cyclopropane, halothane, or trichloroethylene with phenylephrine may increase the risk of severe ventricular arrhythmias because these anesthetics greatly sensitize the myocardium to the effects of sympathomimetic amines; phenylephrine should be used with caution and in substantially reduced dosage in patients receiving these anesthetics. Enflurane, isoflurane, or methoxyflurane may also cause some sensitization of the myocardium to the effects of sympathomimetic amines.
• Anesthetics, parenteral-local – Phenylephrine should be used cautiously and in carefully circumscribed quantities, if at all, with local anesthetics for anesthetizing areas with end arteries (such as the fingers, toes, or penis) or otherwise compromised blood supply; ischemia leading to gangrene may result.
• Anticholinergics - Concurrent use with anticholinergics may intensify anticholinergic effects; patients should be advised to report occurrence of gastrointestinal problems promptly since paralytic ileus may occur with concurrent therapy.
• Antidepressants, tricyclic or maprotiline - Concurrent use may potentiate the cardiovascular effects of phenylephrine, possibly resulting in arrhythmias, tachycardia, or severe hypertension or hyperpyrexia.
• Antihypertensives, or diuretics use as - Antihypertensive effects may be reduced when these medications are used concurrently with phenylephrine; the patient should be carefully monitored to confirm that the desired effect is being obtained.
• β-adrenergic blocking agents - Therapeutic effects may be inhibited when these medications are used concurrently with phenylephrine, especially larger doses; also β-adrenergic blockage may result in unopposed α- adrenergic activity with a risk of hypertension and excessive bradycardia with possible heart block.
• CNS Depressants - Concurrent use of antihistamines with alcohol, tricyclic antidepressants, barbiturates and other CNS depressants may have an additive effect.
• Cocaine, mucosal-local – Concurrent use with phenylephrine may increase the cardiovascular effects of either or both medications and the risk of adverse side effects.
• Digitalis glycosides - Concurrent use with phenylephrine may increase the risk of cardiac arrhythmias; caution and ECG monitoring are necessary if concurrent use is required.
• Ergoloid mesylates or Ergotamine - Concurrent use of ergoloid mesylates or ergotamine with phenylephrine may produce peripheral vascular ischemia and gangrene, and is not recommended. Concurrent use of ergotamine with phenylephrine may potentiate the pressor effect of phenylephrine, resulting in possible severe hypertension and rupture of cerebral blood vessels.
• Doxapram - Concurrent use may increase the pressor effects of either doxapram or phenylephrine.
• Ketoconazole - Anticholinergics may increase gastrointestinal pH, possibly resulting in a marked reduction in ketoconazole absorption during concurrent use with anticholinergics; patients should be advised to take these medications at least 2 hours after ketoconazole.
• Methyldopa - In addition to possibly decreasing the hypotensive effects of these medications, concurrent use may enhance the pressor response to phenylephrine; caution is required with very small initial doses of methyldopa being administered.
• MAO inhibitors - Concurrent use may prolong and intensify cardiac stimulant and vasopressor effects of phenylephrine and chlorpheniramine because of the release of catecholamines, resulting in headache, cardiac arrhythmias, vomiting or sudden and severe hypertensive and/or hyperpyrexic crises. These medications should not be administered during or within 14 days following the administration of MAO inhibitor therapy.
• Potassium chloride - Concurrent use with anticholinergics may increase the severity of potassium chloride induced gastrointestinal lesions.
• Rauwolfia alkaloids - Concurrent use may prolong the direct-acting sympathomimetic amines by preventing the uptake into storage granules.
DRUG & OR LABORATORY TEST INTERACTIONS
Antihistamines may interfere with diagnostic test results for skin tests using allergen extracts. Anticholinergics may interfere with diagnostic test results for gastric acid secretion by antagonizing the effect of pentagastrin and histamine, and for radionuclide gastric emptying studies by delaying gastric emptying.
Carcinogenesis, Mutagenesis, Impairment of Fertility
No data are available on the long-term potential of the components of this product for carcinogenesis, mutagenesis or impairment of fertility in animals or humans.
Category C: Reproduction studies have been performed with chlorpheniramine maleate. Studies in rabbits and rats at doses up to 50 times and 85 times the human dose revealed no evidence of harm to the fetus. There are, however, no adequate and well controlled studies in pregnant women. Therefore, it is not known whether these drugs can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Animal reproduction studies have not been conducted with phenylephrine or methscopolamine. This product should be given to a pregnant woman only if clearly needed.
Labor and Delivery
Use of phenylephrine during labor may cause fetal anoxia and bradycardia by increasing contractility of the uterus and decreasing uterine blood flow.
Small amounts of sympathomimetic amines and antihistamines are excreted in breast milk; use is not recommended because of the risk of adverse effects, such as unusual excitement or irritability, in infants. Anticholinergics and antihistamines may inhibit lactation.
Use of antihistamines is not recommended in newborn or premature infants because this age group has an increased susceptibility to anticholinergic side effects, such as CNS excitation, and an increased tendency toward convulsion. In infants and children, overdosage may cause hallucinations, convulsions, and death. A paradoxical reaction characterized by hyperexcitability may occur in older children taking antihistamines.
Use is not recommended for children under six years of age. Infants and young children are especially susceptible to the toxic effects of anticholinergics. Close supervision is recommended for infants and children with spastic paralysis or brain damage since an increased response to anticholinergics has been reported in these patients, and dosage adjustments are often required. When anticholinergics are given to children where the environmental temperature is high, there is a risk of a rapid increase in body temperature of suppression of sweat gland activity. A paradoxical reaction characterized by hyperexcitability may occur in children taking large doses of anticholinergics. Appropriate studies with phenylephrine have not been performed in the pediatric population; however, no pediatric specific problems have been documented to date.
Confusion, hallucinations, seizures and CNS depression may be more likely to occur in geriatric patients taking sympathomimetic amines. Geriatric patients also may be more sensitive to the effects, especially the vasopressor effects, of sympathomimetic amines. Confusion, dizziness, sedation, hypotension, hyperexcitability, and anticholinergic side effects, such as dryness of mouth and urinary retention (especially in males), may be more likely to occur in geriatric patients taking antihistamines.
Geriatric patients may respond to usual doses of anticholinergics with excitement, agitation, drowsiness, or confusion. Geriatric patients are especially susceptible to the anticholinergic side effects, such as constipation, dryness of mouth, and urinary retention (especially in males). If these side effects occur and continue or are severe, medication should probably be discontinued.
Caution is also recommended when anticholinergics are given to geriatric patients, because of the danger of precipitating undiagnosed glaucoma. Memory may become severely impaired in geriatric patients, especially those who already have memory problems, with the continued use of anticholinergics, since these drugs block the action of acetylcholine, which is responsible for many functions of the brain, including memory function.
The following adverse reactions have been observed with the use of, chlorpheniramine, methscopolamine and phenylephrine:
Arrhythmias, blood dyscrasias, CNS depression, CNS stimulation, dizziness, drowsiness, dryness of mouth, hallucinations, hypotension, hypertension, increased sensitivity of skin to sun, increased sweating, loss of appetite, paradoxical reaction, restlessness, skin rash, stomach upset or pain, thickening of mucus, tingling in hands or feet, trembling, troubled breathing, unusual tiredness or weakness, vomiting.
Note: • Agitation; confusion; difficult or painful urination; drowsiness; dizziness; and dryness of mouth, nose or throat are more likely to occur in the elderly.
• Nightmares, unusual excitement, nervousness, restlessness, or irritability are more likely to occur in children and the elderly.
• When anticholinergics are given to patients, especially children, where the environmental temperature is high, there is risk of a rapid increase in body temperature.
DRUG ABUSE AND DEPENDENCE
Central nervous system stimulants such as phenylephrine have been abused. At high doses, subjects commonly experience an elevation of mood, a sense of increased energy and alertness, and decreased appetite. Some individuals become anxious, irritable and loquacious. In addition to the marked euphoria, the user experiences a sense of markedly enhanced physical strength and mental capacity. With continued use, tolerance develops, the user increases the dose, and toxic signs and symptoms appear. Depression may follow rapid withdrawal. Stimulants, such as phenylephrine, are banned and tested for by the U.S. Olympic Committee (USOC) and the National Collegiate Athletic Association (NCAA).
This product is comprised of pharmacologically different components (antihistamine, anticholinergic, and sympathomimetic amine,). Therefore, it is difficult to predict the exact manifestation of symptoms in a given individual. Reaction to an overdose of this product may vary from CNS depression to stimulation. A description of symptoms which are likely to appear after ingestion of an excess of the individual components follows:
• Overdosage with sympathomimetic amines can cause cardiac arrhythmias, cerebral hemorrhage and pulmonary edema. It can also cause palpitations, tremor, dizziness, vomiting, fear, labored breathing, headache, dryness of mouth, pallor, weakness, panic, anxiety, confusion, and hallucination.
• Manifestation of antihistamine overdosage may vary from CNS depression to stimulation. Other signs and symptoms may be dizziness, tinnitus, ataxia, blurred vision, and hypotension. Stimulation is particularly likely in children as are atropine-like signs and symptoms (dry mouth, fixed dilated pupils, flushing, hyperthermia, and gastrointestinal symptoms). In infants and children particularly, antihistamines in overdosage may produce convulsion and/or death.
• The signs and symptoms of overdosage of anticholinergics are headache, nausea, vomiting, blurred vision, fixed and dilated pupils, hot dry skin, dizziness, dryness of mouth, difficulty in swallowing, and CNS stimulation
Treatment of acute overdosage would probably be based upon treating the patient for phenylephrine toxicity which may manifest itself as excessive CNS stimulation resulting in excitement, tremor, restlessness, and insomnia. Other effects may include hyperpyrexia, hypertension, mydriasis, hyperglycemia and urinary retention. Severe overdosage may cause tachypnea or hyperpnea, convulsions or delirium, but in some individuals there may be CNS depression with somnolence, stupor, or respiratory depression. Arrhythmias may lead to hypotension and circulatory collapse. Severe hypokalemia can occur, probably due to a compartmental shift rather than a depletion of potassium. No organ damage or significant metabolic derangement is associated with overdosage.
Treatment is symptomatic and supportive with possible utilization of the following:
• Induction of emesis (syrup of Ipecac recommended); however, precaution against aspiration is necessary, especially in infants and children.
• Gastric lavage (isotonic or 0.45% sodium chloride solution) if patient is unable to vomit within three hours of ingestion.
• Saline cathartics (milk of magnesia) are sometimes used.
• Vasopressors to treat hypotension; however epinephrine should not be used since it may further lower blood pressure.
• For excessive hypertensive effect an adrenergic blocker, such as phentolamine, may be administered.
• Hyperpyrexia, especially in children, may require treatment with tepid water sponge bath or hypothermic blankets.
• Excessive CNS stimulation may be counteracted with parenteral diazepam.
• Oxygen and intravenous fluids.
• Precaution against the use of stimulants (analeptic agents) is recommended because they may cause seizures.
• Excitement to a degree which demands attention may be managed with sodium thiopental 2% solution given slowly intravenously or chloral hydrate (100-200 mL of a 2% solution) by rectal infusion. In severe cases of overdosage it is essential to monitor both the heart (by electrocardiograph) and plasma electrolytes, and to give intravenous potassium as indicated. In the event of progression of the curare-like effect to paralysis of the respiratory muscles or apnea, artificial respiration should be instituted and maintained until effective respiratory action returns.
DOSAGE AND ADMINISTRATION
Dallergy Chewable Tablets: Adults and children 12 years of age and older: 1 to 2 tablets every 4-6 hours not to exceed eight tablets daily; Children 6 to under 12 years: ½ to 1 tablet every 4-6 hours not to exceed four tablets daily. Not recommended for children under 6 years of age.
Dallergy Chewable Tablets are mottled-purple, grape flavored, capsule-shaped, chewable tablets with “LAS 152” debossed on one side. The opposite side is scored. Available in bottles of 100 tablets (NDC 68134-152-01).
Storage and Handling
Store at 20°-25°C (68°-77°F); excursions permitted to 15°- 30°C (59°-86°F). See USP Controlled Room Temperature.
Dispense in a tight, light-resistant container as defined in the USP/NF with a child resistant closure.
KEEP THIS AND ALL MEDICATION OUT OF THE REACH OF CHILDREN. IN CASE OF ACCIDENTAL OVERDOSE, SEEK PROFESSIONAL ASSISTANCE OR CONTACT A POISON CONTROL CENTER IMMEDIATELY.
500397 Rev. 04/2010
Revised: 05/2010 Palmetto Pharmaceuticals, Inc.
Reproduced with permission of U.S. National Library of Medicine
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