Consumer medicine information

APO-Moclobemide

Moclobemide

BRAND INFORMATION

Brand name

APO-Moclobemide

Active ingredient

Moclobemide

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using APO-Moclobemide.

What is in this leaflet

This leaflet answers some common questions about moclobemide. It does not contain all the available information. It does not take the place of talking to your doctor or pharmacist.

All medicines have risks and benefits. Your doctor has weighed the risks of you using this medicine against the benefits they expect it will have for you.

If you have any concerns about taking this medicine, ask your doctor or pharmacist.

Keep this leaflet with the medicine. You may want to read it again.

What this medicine is used for

Moclobemide is used to treat depression. It belongs to a group of antidepressant medicines called reversible inhibitors of monoamine oxidase A (RIMA).

How it works

Antidepressants are used to treat depression and work on the central nervous system. They are thought to work by their action on brain chemicals called amines, which are involved in controlling mood.

Depression is longer lasting and/or more severe than the "low moods" everyone has from time to time due to the stress of everyday life. It is thought to be caused by a chemical imbalance in parts of the brain. This imbalance affects your whole body and can cause emotional and physical symptoms such as feeling low in spirit, loss of interest in activities, being unable to enjoy life, poor appetite or overeating, disturbed sleep, often waking up early, loss of sex drive, lack of energy and feeling guilty over nothing.

Moclobemide helps to correct this chemical imbalance and may help relieve the symptoms of depression.

Ask your doctor if you have any questions about why this medicine has been prescribed for you. Your doctor may have prescribed moclobemide for another reason.

This medicine is available only with a doctor's prescription.

This medicine is not addictive.

There is not enough information to recommend the use of this medicine in children under 18 years of age.

Before you take this medicine

When you must not take it

Do not take this medicine if you have an allergy to:

  • moclobemide
  • any of the ingredients listed at the end of this leaflet.

Some of the symptoms of an allergic reaction may include:

  • cough, shortness of breath
  • wheezing or difficulty breathing
  • swelling of the face, lips, tongue, throat or other parts of the body
  • rash, itching or hives on the skin
  • fainting
  • hayfever-like symptoms.

Do not take this medicine if you are taking other medications known as selective serotonin reuptake inhibitors, tricyclic antidepressants, or clomipramine, selegiline, bupropion, triptans, pethidine, tramadol, dextromethorphan or linezolid. A serious reaction called serotonin syndrome may occur if you take moclobemide with the above medicines. This can cause a sudden increase in body temperature, high blood pressure and convulsions (fits).

Do not take this medicine if you are suffering from or have had recent episodes of severe confusion.

Do not take this medicine after the expiry date has passed or if the packaging is torn or shows signs of tampering. If it has expired or is damaged, return it to your pharmacist for disposal.

If you are not sure whether you should start taking this medicine, talk to your doctor.

Before you start to take it

Tell your doctor if you have allergies to any other medicines, foods, preservatives or dyes.

Tell your doctor if you have or have had any of the following medical conditions:

  • any mental illness including bipolar disorder, schizophrenia, agitation and excitation
  • history or family history of suicide, bipolar disorder or depression
  • liver disease
  • high blood pressure
  • thyrotoxicosis (excessive amount of thyroid hormone)
  • phaeochromocytoma (a rare tumour of the adrenal gland).

Tell your doctor if you are pregnant or plan to become pregnant. Do not take this medicine whilst pregnant until you and your doctor have discussed the risks and benefits involved.

Tell your doctor if you are breastfeeding. A small amount of moclobemide passes into breast milk and may affect your baby. Your doctor will discuss with you the risks and benefits involved.

Tell your doctor if you are planning to have surgery, dental treatment or an anaesthetic.

If you have not told your doctor about any of the above, tell them before you start taking this medicine.

Taking other medicines

Tell your doctor or pharmacist if you are taking any other medicines, including any that you get without a prescription from your pharmacy, supermarket or health food shop.

You MUST NOT take moclobemide with:

  • clomipramine
  • selegiline
  • selective serotonin reuptake inhibitors, such as fluoxetine, paroxetine, sertraline
  • tricyclic antidepressants, such as amitriptyline or nortriptyline
  • dextromethorphan, a cough suppressant (ingredient in some cold & flu preparations)
  • a class of medicines called triptans, used for treating migraine for example sumatriptan
  • pethidine, a pain reliever
  • bupropion, an antidepressant
  • tramadol
  • linezolid.

Taking these medicines may increase the chance of you developing serotonin syndrome.

Some medicines and moclobemide may interfere with each other. These include:

  • cimetidine, an anti-ulcer drug
  • opiate pain killers, such as dextropropoxyphene, morphine, fentanyl and codeine
  • other types mood disorder therapies called MAOIs, venlafaxine or St John's wort
  • omeprazole, used for stomach acid reduction
  • metoprolol, used for treating certain heart problems, angina, or high blood pressure.

Moclobemide may cause an additional drop in blood pressure if you are taking metoprolol.

These medicines may be affected by moclobemide or may affect how well it works. You may need different amounts of your medicines, or you may need to take different medicines.

Your doctor may have more information on medicines to be careful with or avoid while taking moclobemide.

Other interactions not listed above may also occur.

In addition, do not eat large quantities of tyramine-containing food (mature cheese, yeast extract, fermented soya bean products) while you are taking moclobemide, especially if you have high blood pressure.

How to take this medicine

Follow all directions given to you by your doctor carefully. They may differ to the information contained in this leaflet.

If you do not understand the instructions on the box, ask your doctor or pharmacist for help.

How much to take

Your doctor will tell you how much of this medicine you should take. This will depend on your condition and whether you are taking any other medicines. If you have liver problems your doctor may prescribe a lower dose.

The usual dose is between 300 mg and 600 mg per day, but you usually start on a lower dose.

If you are changing from one antidepressant to another, follow your doctor's instructions carefully and report any unexpected effects.

How to take it

Swallow the tablets whole with a glass of water.

When to take it

Moclobemide is usually taken twice a day (e.g. morning and evening), at the end of a meal.

Take this medicine at about the same time each day. Taking it at the same time each day will have the best effect. It will also help you remember when to take it.

How long to take it for

Continue taking your medicine for as long as your doctor tells you.

The length of treatment with an antidepressant will depend on how quickly your symptoms improve. Most antidepressants take time to work, so don't be discouraged if you don't feel better right away. Some of your symptoms may improve in 1-2 weeks, but it can take up to 4-6 weeks to feel any real improvement.

Even when you feel well, you will usually have to take your medicine for several months or even longer to make sure the benefits will last.

Make sure you have enough to last over weekends and holidays.

Occasionally the symptoms of depression or other psychiatric conditions may include thoughts of harming yourself or committing suicide. It is possible that these symptoms may continue or increase until the full anti-depressant effect of your medicine becomes apparent (i.e. one to two months).

You or anyone close to you or caring for you should watch for these symptoms and tell your doctor immediately or go to the nearest hospital if you have any distressing thoughts or experiences during this initial period or at any other time.

Contact your doctor if you experience any worsening of your depression or other symptoms at any time during your treatment.

If you forget to take it

If it is almost time to take your next dose, skip the dose you missed and take your next dose when you are meant to.

Otherwise, take it as soon as you remember, and then go back to taking your medicine as you would normally.

Do not take a double dose to make up for missed doses. This may increase the chance of unwanted side effects.

If you have trouble remembering to take your medicine, ask your pharmacist for some hints.

If you take too much (overdose)

Immediately telephone your doctor or the Poisons Information Centre (telephone 13 11 26) for advice, or go to Accident and Emergency at your nearest hospital, if you think that you or anyone else may have taken too much of this medicine. Do this even if there are no signs of discomfort or poisoning. You may need urgent medical attention.

If you take too much moclobemide, you may get nausea, vomiting, drowsiness, disorientation, memory loss, slurred speech, reduced reflexes, agitation, high blood pressure and/or convulsions (fits).

While you are taking this medicine

Things you must do

Contact a doctor immediately or go to the nearest hospital for treatment, if you or someone you know or care for demonstrates any of the following warning signs of suicide-related behaviour while taking moclobemide:

  • thoughts or talk of death or suicide
  • thoughts of talk of self-harm or harm to others
  • any recent attempts of suicide or self-harm
  • increase in aggressive behaviour, irritability or agitation
  • worsening of depression.

All mentions of suicide or violence must be taken seriously.

If you are about to be started on any new medicine, remind your doctor that you are taking this medicine.

Tell any other doctors, dentists and pharmacists who are treating you that you take this medicine.

If you become pregnant, tell your doctor immediately.

Tell your doctor if you are going to have surgery or an anaesthetic or are going into hospital.

Tell your doctor if, for any reason, you have not taken your medicine exactly as prescribed. Otherwise, your doctor may think that it was not effective and change your treatment unnecessarily.

Tell your doctor if you feel the tablets are not helping your condition.

When you are being treated for depression, be sure to discuss with your doctor any problems you may have and how you feel. This will help your doctor to determine the best treatment for you.

Keep all of your doctor's appointments so that your progress can be checked. Your doctor may occasionally do tests to make sure the medicine is working and to prevent side effects.

Things you must not do

Do not give this medicine to anyone else, even if they have the same condition as you.

Do not take your medicine to treat any other complaints unless your doctor tells you to.

Do not stop taking your medicine or change the dosage without checking with your doctor.

Things to be careful of

Be careful driving or operating machinery until you know how this medicine affects you. Moclobemide generally does not cause any problems with your ability to drive a car or operate machinery. However, moclobemide may cause dizziness or tiredness in some people. If you have any of these symptoms, do not drive, operate machinery or do anything else that could be dangerous.

Although drinking alcohol is unlikely to affect your response to moclobemide, your doctor may suggest avoiding alcohol while you are being treated for depression.

Side effects

Tell your doctor or pharmacist as soon as possible if you do not feel well while you are taking moclobemide.

This medicine helps most people with depression, but it may have unwanted side effects in a few people. All medicines can have side effects. Sometimes they are serious, most of the time they are not. You may need medical attention if you get some of the side effects.

Do not be alarmed by the following lists of side effects. You may not experience any of them.

Ask your doctor or pharmacist to answer any questions you may have.

In the first week or two you may experience:

  • sleep disturbances
  • dizziness
  • nausea
  • headache
  • nervousness
  • dry mouth
  • occasionally, the symptoms of depression may include thoughts of suicide or self-harm. These symptoms may continue or get worse during the first one to two months of treatment until the full antidepressant effect of the medicine becomes apparent. This is more likely to occur if you are a young adult under 24 years of age.

Tell your doctor or pharmacist if you notice any of the following and they worry you:

  • insomnia, disturbed sleep, restlessness, feeling apathetic or tired
  • dizziness
  • stomach complaints, such as upset stomach, heartburn or stomach pain, nausea, diarrhoea, decreased appetite, constipation, trapped wind, feeling of fullness
  • vomiting
  • headache or migraine
  • anxiety or tense feelings
  • feeling of confusion or being disoriented, forgetfulness
  • dry mouth, changed taste sensation, problems speaking, sore mouth or gums
  • blurred vision, red, itchy eyes
  • mild skin rash
  • flushing or cold sensation
  • shaking or twitching
  • paraesthesia, numbness or tingling in the fingers
  • ringing in the ears
  • muscle or bone pain
  • an urge to urinate or defecate
  • hypotension

The above list includes the more common side effects and some rarer ones. Mostly, these are mild.

Tell your doctor as soon as possible if you notice any of the following:

  • change in the colour, frequency or volume of urine
  • sight problems, seeing flashing lights
  • troubled breathing
  • high blood pressure
  • slow heart beat
  • hallucinations (seeing, feeling or hearing things that are not there)
  • swollen veins
  • dry skin, itchy skin or hives
  • unusual vaginal bleeding, or prolonged menstruation.

The above list includes serious side effects that may require medical attention.

If any of the following happen, stop taking moclobemide and contact your doctor immediately or go to Accident and Emergency at your nearest hospital:

  • early signs of mania, such as sense of grandeur, hyperactivity(including increased speech), reckless and impulsive behaviour.
  • thoughts or talk of death or suicide
  • thoughts or talk of self-harm or harm to others.
    All mentions of suicide or violence must be taken seriously.
  • any recent attempts of self-harm
  • increase in aggressive behaviour, irritability or agitation
  • worsening of depression.
  • sudden increase in body temperature, agitation, shivering, severe convulsions
  • fast heartbeat, sweating, muscle spasm, racing thoughts, restlessness
  • angina or chest pain.
  • cough, shortness of breath, wheezing or difficulty breathing; swelling of the face, lips, tongue, or other parts of the body; rash, itching or hives on the skin; fainting; hayfever-like symptoms (signs of an allergic reaction)

The above list includes very serious side effects. You may need urgent medical attention or hospitalisation.

Tell your doctor or pharmacist if you notice anything that is making you feel unwell.

Other side effects not listed above may occur in some patients.

Storage and disposal

Storage

Keep your tablets in the pack until it is time to take them. If you take them out of the pack, they may not keep well.

Keep your medicine in a cool dry place where the temperature stays below 25°C.

Do not store your medicine or any other medicine in the bathroom or near a sink. Do not leave it on a window sill or in the car. Heat and dampness can destroy some medicines.

Keep it where children cannot reach it. A locked cupboard at least one-and-a-half metres above the ground is a good place to store medicines.

Disposal

If your doctor tells you to stop taking this medicine or the expiry date has passed, ask your pharmacist what to do with any medicine that is left over.

Product description

What it looks like

150 mg tablets:
Pale yellow, oval, biconvex, film-coated tablets, scored on one side and engraved "APO" over "150" on the other. AUST R 73831.

300 mg tablets:
White, oval, biconvex, film-coated tablets, scored on one side and engraved "APO" over "300" on the other. AUST R 73835.

Available in blister packs of 60 tablets.

Ingredients

Each tablet contains 150 mg or 300 mg of moclobemide as the active ingredient.

The 150 mg tablets also contain the following:

  • dextrates
  • croscarmellose sodium
  • magnesium stearate
  • colloidal anhydrous silica
  • hypromellose
  • polydextrose
  • macrogol 3350
  • titanium dioxide
  • iron oxide yellow
  • carnauba wax.

The 300 mg tablets also contain the following:

  • methylcellulose
  • microcrystalline cellulose
  • croscarmellose sodium
  • magnesium stearate
  • colloidal anhydrous silica
  • hypromellose
  • hyprolose
  • macrogol 8000
  • titanium dioxide.

This medicine does not contain gluten, lactose, sucrose, tartrazine or any other azo dyes.

Sponsor

Apotex Pty Ltd
16 Giffnock Avenue
Macquarie Park NSW 2113.

Apotex Pty Ltd is the licensee of the registered trademarks APO and APOTEX from registered proprietor, Apotex Inc.

This leaflet was updated in October 2021.

Published by MIMS November 2021

BRAND INFORMATION

Brand name

APO-Moclobemide

Active ingredient

Moclobemide

Schedule

S4

 

1 Name of Medicine

Moclobemide.

2 Qualitative and Quantitative Composition

Each tablet contains 150 mg or 300 mg moclobemide, as the active ingredient.
For the full list of excipients see Section 6.1 List of Excipients.

3 Pharmaceutical Form

150 mg tablets.

Pale yellow, oval, biconvex, film-coated tablets, scored on one side and engraved "APO" over "150" on the other.

300 mg tablets.

White, oval, biconvex, film-coated tablets, scored on one side and engraved "APO" over "300" on the other.

4 Clinical Particulars

4.1 Therapeutic Indications

Treatment of major depression.

4.2 Dose and Method of Administration

APO-Moclobemide Tablets are intended for oral administration.

Dosage.

Adults.

Moclobemide therapy should be initiated in two divided daily doses. The recommended initial daily dose is 300 or 450 mg. The recommended dose range is 300-600 mg/day. The dose should not be raised until after the first week, as bioavailability increases during this period. Treatment should continue for at least 4-6 weeks in order to assess the efficacy of the drug. Moclobemide should be taken after meals.

Dosage in the elderly.

No dosage adjustments are necessary in elderly patients.

Renal impairment.

Single dose pharmacokinetic data suggest that no dosage adjustment may be required in patients with reduced renal function. However, multiple dose studies with moclobemide have not been performed in patients with renal dysfunction, therefore moclobemide should be used with caution in this patient population. In normal volunteers, the absolute bioavailability almost doubles following multiple dosing as compared to a single dose.

Hepatic impairment.

In patients with severely impaired hepatic metabolism, the daily dose of moclobemide should be reduced to 1/2 or 1/3 of the dose to reach the usual plasma level.

4.3 Contraindications

Known hypersensitivity to the active ingredient or excipients in this medicine (see Section 6.1 List of Excipients).
Acute confusional states.
Serotonin Syndrome (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).
Co-administration of moclobemide with clomipramine should be avoided in clinical practice due to the risks of increased incidence of adverse reactions.
Co-administration of moclobemide with the following drugs is contraindicated (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions): selegiline (L-deprenyl), bupropion, triptans, pethidine, tramadol, dextromethorphan, linezolid.

4.4 Special Warnings and Precautions for Use

Clinical worsening and suicide risk.

The risk of suicide attempt is inherent in depression and may persist until significant remission occurs. This risk must be considered in all depressed patients. Antidepressants increased the risk compared to placebo of suicidality in children, adolescents and young adults (aged 18-24 years) during initial treatment (generally the first one to two months) in short-term studies of major depression and other psychiatric disorders. Short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults over 24 years of age and there was a reduction in risk with antidepressants compared to placebo in adults 65 years or older.
Pooled analyses of 24 short-term (4 to 16 weeks), placebo-controlled trials of nine antidepressant medicines (SSRIs and others) in 4400 children and adolescents with major depressive disorder (16 trials), obsessive compulsive disorder (4 trials) or other psychiatric disorders (4 trials) have revealed a greater risk of adverse events representing suicidal behaviour or thinking (suicidality) during the first few months of treatment in those receiving antidepressants. The average risk of such events in patients treated with an antidepressant was 4% compared with 2% of patients given placebo. There was considerable variation in risk among the antidepressants, but there was a tendency towards an increase for almost all antidepressants studied. The risk of suicidality was most consistently observed in the major depressive disorder trials, but there were signals of risk arising from trials in other psychiatric indications (obsessive compulsive disorder and social anxiety disorder) as well. No suicides occurred in these trials. It is unknown whether the suicidality risk in children and adolescent patients extends to use beyond several months. The nine antidepressant medicines in the pooled analyses included five SSRIs (citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline) and four non-SSRIs (bupropion, mirtazapine, nefazodone, venlafaxine).
Families and caregivers of children and adolescents being treated with antidepressants for major depressive disorder or for any other conditions (psychiatric or non-psychiatric) should be informed about the need to monitor these patients for the emergence of agitation, irritability, unusual changes in behaviour and other symptoms described above, as well as the emergence of suicidality, and to report such symptoms immediately to health care providers. It is particularly important that monitoring be undertaken during the initial few months of antidepressant treatment or at times of dose increase or decrease.
Patients with depression may experience worsening of their depressive symptoms and/or the emergence of suicidal ideation and behaviours (suicidality) whether or not they are taking antidepressant medications and this risk may persist until significant remission occurs. As improvement may not occur during the first few weeks or more of treatment, patients should be closely monitored for clinical worsening and suicidality, especially at the beginning of a course of treatment, or at the time of dose changes, either increases or decreases. Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse or whose emergent suicidality is severe, abrupt in onset or was not part of the patient's presenting symptoms. Patients (and caregivers of patients) should be alerted about the need to monitor for any worsening of their condition and/or the emergence of suicidal ideation/behaviour or thoughts of harming themselves and to seek medical advice immediately if these symptoms present. Patients with co-morbid depression associated with other psychiatric disorders being treated with antidepressants should be similarly observed for clinical worsening and suicidality.
Patients with a history of suicide-related events, or those exhibiting a significant degree of suicidal ideation prior to commencement of treatment are known to be at greater risk of suicidal thoughts or suicide attempts, and should receive careful monitoring during treatment.
Symptoms of anxiety, agitation, panic attacks, insomnia, irritability, hostility (aggressiveness), impulsivity, akathisia (psychomotor restlessness), hypomania and mania have been reported in adults, adolescents and children being treated with antidepressants for major depressive disorder as well as for other indications, both psychiatric and non-psychiatric. Although a causal link between the emergence of such symptoms and either worsening of depression and/or emergence of suicidal impulses has not been established, there is concern that such symptoms may be precursors of emerging suicidality.
Prescriptions for moclobemide should be written for the smallest quantity of tablets consistent with good patient management, in order to reduce the risk of overdose. Insomnia or nervousness or jitteriness at the beginning of treatment with moclobemide can justify a dose reduction or temporary symptomatic treatment. In case of occurrence of mania or hypomania, or the onset of early symptoms of those reactions (grandiosity, hyperactivity (including increased speech), reckless impulsivity) treatment with moclobemide will be interrupted and alternative treatment will be initiated.

Bipolar disorder/ mania.

A major depressive episode may be the initial presentation of bipolar disorder. It is generally believed that treating such an episode with an antidepressant alone can increase the likelihood of precipitation of a mixed/manic episode in patients at risk of bipolar disorder. Prior to initiating treatment with an antidepressant, patients should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder and depression.

Patients with excitation or agitation as main clinical feature.

Treatment of depressed patients with excitation or agitation as the main clinical feature may require addition of benzodiazepines.

Patients with schizophrenic symptoms.

As is the case with other antidepressants, an exacerbation of schizophrenic symptoms is possible when depressive patients with schizophrenic or schizoaffective psychoses are treated. Therapy with long-term neuroleptics should, if possible, be maintained in such patients.

Dietary precaution.

Treatment with moclobemide does not necessitate dietary restrictions in patients with normal dietary habits. Hypertensive patients are advised to avoid large quantities of tyramine-rich food such as ripe cheese (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

St. John's wort.

St. John's wort (Hypericum)-containing phytotherapeutic products should be used with care in combination with moclobemide as this may increase the serotonin concentration.

Hypertensive reactions.

There are theoretical pharmacological grounds for supposing that drugs that inhibit monoamine oxidase may provoke hypertensive reactions in patients with thyrotoxicosis or pheochromocytoma. In the absence of relevant experience with moclobemide, the drug should be prescribed with caution for patients in these groups.

Use in the elderly.

No data available.

Paediatric use.

The safety and efficacy of moclobemide for the treatment of depression or other psychiatric disorders in children and adolescents aged less than 18 years has not been satisfactorily established. Moclobemide should not be used in this age group for the treatment of depression or other psychiatric disorders.

Effects on laboratory tests.

Moclobemide does not affect laboratory tests.

4.5 Interactions with Other Medicines and Other Forms of Interactions

Selegiline.

Co-administration of moclobemide with selegiline is contraindicated due to the relative loss of selectivity if both monoamine oxidase A and B are inhibited.

Linezolid.

Co-administration of moclobemide with linezolid is contraindicated due to the increased risk of serotonin syndrome and hypertensive crisis in vulnerable individuals.

Tramadol.

Co-administration of moclobemide with tramadol is contraindicated.

Pethidine.

High dose studies in animals have demonstrated some potentiation of analgesic effect and increased restlessness with concomitant administration of pethidine and moclobemide. Concomitant administration of pethidine and moclobemide is contraindicated because of the increased risk of serotonergic syndrome (confusion, fever, convulsions, ataxia, hyperreflexia, myoclonus, diarrhoea).

Dextromethorphan.

Isolated cases of severe central nervous system adverse reactions have been reported after co-administration of moclobemide and dextromethorphan. Co-administration of moclobemide and dextromethorphan, which may be contained in cough cold medicines, is not recommended and if possible, alternatives not containing dextromethorphan should be given (see Section 4.4 Special Warnings and Precautions for Use).

Dextropropoxyphene.

Concomitant use of dextropropoxyphene is not advised as moclobemide may potentiate the effects of dextropropoxyphene.

Opiates.

In animals, moclobemide potentiates the effects of opiates. A dosage adjustment of the following opiate, e.g. morphine, fentanyl and codeine may therefore be necessary.

Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), irreversible MAO inhibitors, serotonin syndrome and washout periods.

Due to the possibility of development of Serotonin Syndrome, moclobemide should not be administered concomitantly with selective serotonin reuptake inhibitors (e.g. fluoxetine and fluvoxamine) or tricyclic antidepressants. This possibility increases with increasing dose and fatalities have occurred where one or more of these drugs have been ingested in overdose (see Section 4.9 Overdose). Generally, in patients receiving moclobemide, additional drugs that enhance serotonin, particularly in multiple-drug combinations, should only be given with caution.
There are limited data (i.e. small clinical pharmacology studies and postmarketing reports) to support the safety of changing from low to moderate doses of serotonin reuptake inhibitors to moclobemide 300 mg/day by ceasing the SSRI on one day and starting moclobemide on the next. In one study, 18 healthy subjects were changed from moclobemide 300 mg on day one to fluoxetine 40 mg/day for the next 7 days then fluoxetine 20 mg/day for a further 7 days. On day 16, subjects were randomised to receive, in addition to fluoxetine 20 mg/day, moclobemide in ascending doses from 100 mg to 600 mg or placebo, for the next 8 days. On day 24, all patients received 300 mg moclobemide. There were no differences in the adverse reactions reported between the two groups, although the power of the study to detect clinically significant interactions is limited, given the number of subjects and the dose of moclobemide used. Caution is, however, recommended and the dose of moclobemide should be held at 300 mg/day for the first week. Particular attention should also be given to the patient's medical history and concomitant therapy with other psychotropic drugs known to interact with or facilitate 5-HT functions.
Similarly, there are limited data to support the safety of changing from low to moderate doses of tricyclic antidepressants, for example 150 mg or less of amitriptyline to moclobemide 300 mg per day by ceasing the tricyclic antidepressant one day and starting moclobemide 300 mg the next. The patient should be seen again soon after the changeover and progress monitored appropriately. The dose of moclobemide should be maintained at 300 mg/day for the first week.
Generally, an interval of 14 days is recommended for switching from an irreversible MAO inhibitor to moclobemide (e.g. phenelzine, tranylcypromine).

Serotonin-norepinephrine reuptake inhibitors (sibutramine and venlafaxine).

In patients receiving moclobemide, additional drugs that enhance serotonin, such as venlafaxine should be given with caution. Concomitant use of sibutramine with moclobemide is not recommended.

Trimipramine and maprotiline.

Care should be taken with concomitant use of trimipramine and maprotiline as the plasma concentration of these non-selective monoamine reuptake inhibitors increases upon concomitant administration with moclobemide.

St. John's wort.

Concomitant use with St. John's wort (Hypericum) is not recommended as this may increase the serotonin concentration in the central nervous system.

Serotonin agonists.

Some serotonin agonists are metabolised predominantly by monoamine oxidase A and may need to be avoided or have their dosage reduced if administered concomitantly with moclobemide.

Triptans.

Co-administration of moclobemide with triptans is contraindicated. Triptans (e.g. sumatriptan, rizatriptan, zolmitriptan, almotriptan) are potent serotonin receptor agonists and are metabolized by monoamine oxidases (MAOs) and various cytochrome P450 enzymes. Co-administration of moclobemide leads to an increase in the plasma concentrations of the triptans. A maximum dose of 5 mg of zolmitriptan is recommended if combined with moclobemide and concomitant treatment is not recommended if moclobemide is administered in higher dose than 150 mg twice daily.

Phenprocoumon.

Concomitant administration of moclobemide, 200 mg three times per day, does not influence the parameters of blood coagulation controlled by phenprocoumon. No data are available regarding warfarin and moclobemide.

Digoxin.

Concomitant administration of moclobemide to elderly patients under chronic digoxin treatment produced no significant changes in the digoxin plasma levels. There were no additional ECG disturbances, particularly no arrhythmias or conductance disturbances. Vital signs and laboratory parameters were also unaltered.

Antihypertensive treatment.

The combination of moclobemide with metoprolol, nifedipine or hydrochlorothiazide, in patients stable on their antihypertensive treatment, was well tolerated and in particular there were no orthostatic reactions. The therapeutic benefits of nifedipine and hydrochlorothiazide were not influenced by moclobemide. The combination of moclobemide and metoprolol led to an additional blood pressure reduction of 10 to 15 mmHg (systolic) and 5 to 10 mmHg (diastolic). The mechanism underlying this effect is not clear. In normotensive subjects moclobemide had no effect on blood pressure.

Sympathomimetic amines.

Possible undesired interactions between moclobemide and directly acting sympathomimetic amines have been investigated in healthy subjects. Phenylephrine (PE) reactivity was investigated by infusion of increasing PE doses before and after moclobemide (100 mg single; 200 mg single; 100 mg three times per day for one week; 200 mg three times per day for three weeks) administration. After the three lowest doses, PE reactivity remained unchanged. After chronic administration of the highest dose there was a slight increase by 1.8 of the sensitivity factor in only four out of the six subjects, in the other two it was unchanged. Thus only after repeated administration of the high therapeutic doses of moclobemide 200 mg three times per day could a slight interaction be observed. PE was given intravenously, but in general it will be used as a nasal decongestant. Recommended use in these indications would be unlikely to result in concentrations of PE which cause relevant blood pressure increases.

Cimetidine.

A pharmacokinetic interaction (reduced moclobemide clearance) occurred in healthy subjects with combined administration of moclobemide and cimetidine. Thus if moclobemide treatment is initiated in a patient pretreated with cimetidine, the lowest dose should be given initially. If cimetidine has to be given after initiation of moclobemide treatment, it may be necessary to lower the moclobemide dose by 50% and to adjust according to clinical requirement.

Proton pump inhibitors (e.g. omeprazole).

Care should be taken with concomitant use of drugs that are metabolised by CYP2C19 as moclobemide is an inhibitor of this enzyme. The plasma concentration of these drugs (such as proton pump inhibitors (e.g. omeprazole)) may be increased when concomitantly used with moclobemide. Similarly, moclobemide inhibits the metabolism of omeprazole in CYP2C19 extensive metabolisers resulting in a doubling of the omeprazole exposure.

Oral contraceptives.

The hormone levels (follicle stimulating hormone, luteinising hormone, oestradiol and progesterone) were not altered when moclobemide was administered concomitantly with combined contraceptives.

Tyramine.

In animal experiments it has been shown that the pressor effects of tyramine are less with moclobemide than with other inhibitors of monoamine oxidase. Results from studies in man have shown that when tyramine is administered intravenously or orally under pharmacological conditions by using a provocative model, moclobemide leads to a slight and short-lasting potentiation of the tyramine pressor effect. The potentiation of the pressor effect was even lower or did not occur when tyramine was mixed with a meal. A high protein or fat content meal further reduced the potentiation. In human studies, it was demonstrated that up to 100 mg tyramine, corresponding to 1000 g to 2000 g of mild or 200 g of strong cheese, or to 70 g Marmite yeast extract, can safely be ingested during chronic treatment with moclobemide 200 mg three times per day post-prandially. Thus an interaction with tyramine rich foods is of no clinical importance during moclobemide treatment under normal conditions and moclobemide taken at the end of a meal. Neither age nor depression influences the interaction.

Alcohol.

Concomitant moclobemide administration did not further reduce performance in subjects with a blood content of alcohol distinctly reducing performance. Also in elderly subjects there was no additional influence at therapeutic doses.

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

There were no adverse effects on the fertility of rats receiving oral moclobemide 100 mg/kg/day (600 mg/m2/day), a dose slightly more than the maximum recommended human dose calculated on a surface area basis.
(Category B3)
Moclobemide and two of its metabolites were found in the amniotic fluid of pregnant rats 5 hours after dosing. Moclobemide lacked teratogenic activity in rats and rabbits at respective oral doses of 200 mg/kg/day (1,200 mg/m2/day) and 100 mg/kg/day (1,100 mg/m2/day), doses which are 2 to 3 times the maximum recommended human dose calculated on a surface area basis.
However, there are no data on safety in human pregnancy and careful evaluation of the potential benefit and hazards to the mother and foetus should precede administration to pregnant women.
 Although only a small amount of moclobemide passes into breast milk (approximately 1/30th of the maternal dose), the benefits of continuing drug therapy for the nursing mother should be weighed against possible risks to the breast-feeding child.

4.7 Effects on Ability to Drive and Use Machines

Impairment of performance in activities requiring complete mental alertness (e.g. driving a motor vehicle) is generally not to be expected with moclobemide. The individual reaction should, however, be monitored during early treatment.

4.8 Adverse Effects (Undesirable Effects)

Moclobemide is usually well tolerated. No adverse event occurred with an increased frequency of more than 5% compared to placebo.
The following transient effects have been observed: sleep disturbances, dizziness, nausea, dry mouth and headache.
In very rare cases confusional states have been observed, but these rapidly disappeared on discontinuation of therapy. Insomnia, or nervousness/jitteriness at the beginning of treatment with moclobemide can justify a dose reduction or temporary symptomatic treatment. See Tables 1 and 2.
Other adverse events with an incidence of < 1% in clinical studies, or reported in post-marketing surveillance are as follows:

Psychiatric.

Nightmares/dreams, hallucinations, memory disturbances, disorientation, delusions, increased depression, excitation/irritability, hypomanic symptoms, aggressive behaviour, apathy, tension. Cases of suicidal ideation and suicidal behaviours have been reported during antidepressant therapy or early after treatment discontinuation (see Section 4.4 Special Warnings and Precautions for Use), though such cases have not been observed following early discontinuation of moclobemide.

Central and peripheral nervous system.

Migraine, extrapyramidal effects, tinnitus, dysarthria.

Gastrointestinal.

Heartburn, gastritis, meteorism, indigestion.

Cardiovascular.

Hypertension, bradycardia, extrasystoles, angina/chest pain, phlebetic symptoms.

Dermatological/ mucocutaneous.

Exanthema/rash, allergic skin reaction, itching, gingivitis, stomatitis, dry skin, conjunctivitis.

Genitourinary.

Disturbances of micturition (dysuria, polyuria, tenesmus), metrorrhagia, prolonged menstruation.

Miscellaneous.

General malaise, skeletal/muscular pain, altered taste sensations, hot flushes/cold sensation, photopsia, dyspnoea, visual disturbances. There appears to be a low incidence of increased hepatic enzymes, without associated clinical sequelae.

Reporting suspected adverse effects.

Reporting suspected adverse reactions after registration 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 at www.tga.gov.au/reporting-problems and contact Apotex Medical Information Enquiries/Adverse Drug Reaction Reporting on 1800 195 055.

4.9 Overdose

The highest reported overdose is 20.55 g of moclobemide.

Symptoms.

The usual signs of overdose with moclobemide alone are nausea, vomiting, drowsiness, disorientation, slurred speech, amnesia, reduced reflexes, agitation, hypertension and convulsions.

Treatment.

As with other antidepressants, combination overdoses of moclobemide and other antidepressants, alcohol and other drugs can be life threatening. Fatalities have been reported in combination overdoses of moclobemide and other drugs. Patients should be hospitalised and closely monitored so that appropriate treatment can be given. Serotonin syndrome symptoms (hypertension, spasm, altered consciousness) have been reported with mixed overdoses with clomipramine or selective serotonin reuptake inhibitors.
Management of overdose should include monitoring of vital signs and consideration of other agents ingested in multiple overdoses. Other measures may include activated charcoal.
For information on the management of overdose, contact the Poisons Information Centre on 131126 (Australia).

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Mechanism of action.

Moclobemide is an antidepressant that affects the monoaminergic cerebral neurotransmitter system by means of a reversible inhibition of monoamine oxidase. There are two types of monoamine oxidases, A and B, which vary in their substrate specificity. Moclobemide is relatively selective for type A monoamine oxidase. At a dose of 300 mg, the inhibition of monoamine oxidase A is approximately 80% while that of monoamine oxidase B is approximately 20-30%. The inhibition is short lasting (approximately 24 hours).
The metabolism of dopamine, noradrenaline and serotonin is decreased by this effect and this leads to increased extracellular concentrations of these neuronal transmitters. As a result of its elevating effect on mood and psychomotor activity, moclobemide relieves symptoms such as dysphoria, exhaustion, lack of drive and poor ability to concentrate. These effects most often appear within the first week of therapy. Although moclobemide has no sedative properties, it does increase total sleep time. Moclobemide does not impair alertness or reaction time.
Moclobemide appears to be suitable for ambulatory treatment as it is not sedating and it does not impair vigilance or ability to react.
Moclobemide is well tolerated. Short-term and long-term animal studies indicate low toxicity. Little hepatic or cardiac toxicity has been observed. There is a low incidence of raised liver enzymes.

Clinical trials.

Depression.

Moclobemide versus placebo.

Clinical efficacy of moclobemide in the treatment of depression has been demonstrated in four randomised, placebo controlled, double-blind trials in a total of 475 patients (180 on moclobemide and 165 on placebo) using moclobemide doses of 200-600 mg/day. Three of these were multicentre trials performed predominantly in out-patients and one was a single-centre study performed predominantly in in-patients. Two of the studies compared moclobemide with placebo in parallel group design and two compared with placebo on one hand and with a tricyclic antidepressant (TCA) on the other. The duration of treatment was for 4-6 weeks.
The largest of these studies included 334 patients (117 on moclobemide, 110 on placebo). The mean final improvement in depression, as assessed by the Hamilton Depression Scale (HAMD) score, was 48.7% for moclobemide and 31.9% for placebo treated patients. A final improvement of ≥ 50% in the HAMD score occurred in 58% of moclobemide and 32% of placebo treated patients. The Clinical Global Impressions (CGI) score at the end of the 6-week treatment period was very good/good in 64.3% of patients for moclobemide and 32.1% for placebo treated patients. The efficacy of moclobemide versus placebo was statistically significant (p < 0.001) on all measured efficacy parameters.
In combining the investigator's global assessment of efficacy for all 4 studies, the efficacy was rated as very good/good in approximately 60% of patients who had received moclobemide and 30% of patients who had received placebo.

Moclobemide versus TCAs.

Moclobemide was compared to TCAs in 19 double-blind studies including a total of 1070 patients (542 on moclobemide and 528 on TCAs). The mean moclobemide dose in these studies was 443 mg/day and score on the HAMD was reduced by ≥ 50% in 56% of patients. Moclobemide was found to have similar efficacy to the TCAs and the CGI was very good/good in 60.8% of moclobemide patients and 60.1% of patients treated with comparative TCAs.

Moclobemide versus irreversible monoamine oxidase inhibitors (MAOIs).

Moclobemide was compared to the irreversible monoamine oxidase inhibitor tranylcypromine in 4 double-blind studies with 159 patients (81 on moclobemide and 78 on tranylcypromine) using moclobemide doses of 150-350 mg/day. The mean final reduction in HAMD score was 63% in the moclobemide group and 59% in the tranylcypromine group. Tolerance was more frequently rated as better in the moclobemide group and the number of patients who prematurely terminated was three times higher in the tranylcypromine group.

Moclobemide single daily versus divided daily dosing.

This was a double-blind, randomised, multicentre trial conducted in 189 patients for 6 weeks. The trial compared administration of single daily doses of moclobemide 450 mg (this could be increased up to 600 mg after 2 weeks) with this same daily dose given as three divided doses. The efficacies of the two dosing regimens were not found to be significantly different. Both the dosing regimens were found to be well tolerated, although there was a significant increase in dizziness and a tendency for nausea, insomnia and headache in the once daily group.

5.2 Pharmacokinetic Properties

Absorption.

After oral administration, moclobemide is completely absorbed from the gastrointestinal tract into the portal blood.
A hepatic first-pass effect reduces the systemically available dose fraction (bioavailability: F). This reduction is more pronounced after single (F: 60%) than after multiple (F: > 80%) doses.
Following the administration of a 300 mg single dose of moclobemide to healthy subjects, peak plasma concentrations ranged from 1.0 to 3.4 microgram/mL (mean Cmax 2.2 microgram/mL) and were reached in 0.8 to 4.0 hours (median Tmax 1.75 hours). Studies using other moclobemide-containing formulations have shown that during the second week of a 100 mg t.i.d. dosing regimen in healthy subjects, the steady-state trough concentrations of moclobemide ranged between 114 nanogram/mL and 517 nanogram/mL. An increase in the dose to 150 mg t.i.d. resulted in a greater than proportional increase in moclobemide steady-state trough concentrations, namely to concentrations ranging between 346 nanogram/mL and 1,828 nanogram/mL.

Distribution.

Due to its lipophilic nature, moclobemide is extensively distributed in the body with an apparent volume of distribution (Vss) of about 1.2 L/kg. Binding of the drug to plasma proteins, mainly albumin, is relatively low (50%). Peak plasma concentrations of moclobemide increase over the first week of therapy and remain stable thereafter. When the daily dose is increased, there is a more than proportional increase in steady-state concentrations.

Metabolism.

The drug is almost entirely metabolised before its elimination from the body. Metabolism occurs largely via oxidative reactions on the morpholine moiety of the molecule. Moclobemide is metabolised in part by the polymorphic isoenzymes CYP2C19 and CYP2D6. Thus, in genetically or drug-induced (via metabolic inhibitors) poor metabolisers, metabolism of the drug may be affected. Approximately 2% of the Caucasian population and 15% of the Asian population can be genetically phenotyped as slow metabolisers, with respect to oxidative hepatic metabolism. It has been found that the area under the curve (AUC) measurement in slow metaboliser subjects is approximately 1.5 times greater than in extensive metaboliser subjects for the same dose of moclobemide. This increase is within the normal range of variation (up to two-fold) typically seen in patients. Two studies conducted to investigate the magnitude of these effects suggest that, due to the presence of multiple alternative metabolic pathways, they are therapeutically unimportant and should not necessitate dosage modifications.
One metabolite, the N-oxide metabolite, has slight pharmacological activity. This and other degradation products with pharmacological activity in vitro or in animal experiments, are present in the systemic circulation of man at very low concentrations only.

Excretion.

Moclobemide is rapidly eliminated from the body. Less than 1% of a dose is excreted renally unchanged. The metabolites formed are eliminated renally. Blood clearance is approximately 20-50 L/hr, the average elimination half life is 2 hours, with a slight increase at increased doses.
Multiple dose studies in the elderly and in patients with renal insufficiency suggest no dose adjustment is necessary to achieve plasma levels similar to those in young healthy subjects.

5.3 Preclinical Safety Data

Genotoxicity.

Moclobemide was not genotoxic in assays for gene mutation, chromosomal damage or DNA damage.

Carcinogenicity.

There was no evidence of carcinogenic effects following dietary administration of moclobemide to mice for 18 months at 250 mg/kg/day (750 mg/m2/day) or to rats for 24 months at 225 mg/kg/day (1,350 mg/m2/day), doses which are 2 to 3 times the maximum recommended human dose calculated on a surface area basis.

6 Pharmaceutical Particulars

6.1 List of Excipients

Croscarmellose sodium, magnesium stearate, colloidal anhydrous silica, hypromellose, titanium dioxide.
In addition the following excipients are added:

150 mg.

Dextrates, polydextrose, macrogol 3350, iron oxide yellow, carnauba wax.

300 mg.

Methylcellulose, microcrystalline cellulose, hyprolose, macrogol 8000.

6.2 Incompatibilities

Incompatibilities were either not assessed or not identified as part of the registration of this medicine.

6.3 Shelf Life

In Australia, information on the shelf life can be found on the public summary of the Australian Register of Therapeutic Goods (ARTG). The expiry date can be found on the packaging.

6.4 Special Precautions for Storage

Store below 25°C.
Protect from heat and moisture.

6.5 Nature and Contents of Container

150 mg tablets.

Blister packs (PVC Aclar/Aluminium silver foil) of 60 tablets. (AUST R 73831).

300 mg tablets.

Blister packs (PVC Aclar/Aluminium silver foil) of 60 tablets. (AUST R 73835).
APO and Apotex are registered trademarks of Apotex Inc.
Not all strengths may be available.

6.6 Special Precautions for Disposal

In Australia, any unused medicine or waste material should be disposed of by taking to your local pharmacy.

6.7 Physicochemical Properties

Moclobemide is a white to slightly reddish crystalline powder. It contains no crystal water and is not hygroscopic. It is soluble in water at 0.4 g/100 mL. The pKa is approximately 6.2.

Chemical structure.


Chemical Name: p-chloro-N-(2-morpholinoethyl)benzamide.
Molecular Formula: C13H17O2N2Cl.
Molecular Weight: 268.74.

CAS number.

71320-77-9.

7 Medicine Schedule (Poisons Standard)

S4 - Prescription Only Medicine.

Summary Table of Changes