Consumer medicine information

Rulide D

Roxithromycin

BRAND INFORMATION

Brand name

Rulide and Rulide D

Active ingredient

Roxithromycin

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Rulide D.

What is in this leaflet

This leaflet answers some common questions about Rulide D.

It does not contain all the available information.

It does not take the place of talking to your doctor or pharmacist.

Your doctor or pharmacist has weighed the benefits of your child taking Rulide D against any possible risk.

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

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

What is Rulide D used for

Rulide D is used mainly to treat respiratory tract infections, and skin and soft tissue infections.

However, your doctor may have prescribed Rulide D for another reason.

Ask your doctor if you have any questions about why Rulide D has been prescribed for your child.

Rulide D (roxithyromycin) is an antibiotic, which belongs to a group of medicines called macrolides.

These antibiotics work by killing the bacteria that are causing the infection. Like all antibiotics Rulide D will not work against viral infections.

Before you take Rulide D

Rulide D must not be taken if:

  1. your child has an allergy to:
  • roxithromycin or any other macrolide eg erythromycin, clarithromycin or azithromycin
  • any of the ingredients listed at the end of this leaflet (see Product Description)
Symptoms of an allergic reaction may include skin rash, itching, difficulty breathing or swelling of the face, lips or tongue, which cause difficulty in swallowing or breathing.
  1. your child has severe liver problems
  2. your child is taking certain medicines for migraine headache called ergot alkaloids
  3. if the packaging is torn or shows signs of tampering or if the expiry date on the pack has passed, please tell your pharmacist

Before you start to take it

Tell your doctor or pharmacist if your child has or has ever had allergies to:

  • any other medicines
  • any other substances, such as foods, preservatives or dyes

Tell your doctor or pharmacist if your child has or has ever had any other health problems/ medical conditions, especially the following:

  • kidney problems (impaired function)
  • liver problems (hepatic cirrhosis with jaundice and/or ascites)

Taking other medicines

Tell your doctor or pharmacist if your child is taking/using any other medicines, including any that you buy without a prescription from your pharmacy, supermarket or health food shop.

Some medicines and Rulide D may interfere with each other. These include theophylline, disopyramide, warfarin, terfenadine, digoxin, midazolam, ciclosporin, cisapride, pimozide, and some migraine medicines.

Your doctor and pharmacist may have more information about medicines, which, if taken at the same time as Rulide D, may require a dosage adjustment.

How to take Rulide D

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

How much to take

For children weighing less than 40 kg, the dosage can range from one half a tablet, one tablet or two tablets twice a day. Your doctor will tell you the correct number of tablets to give your child.

How to take it

Follow the instructions below on how to give your child Rulide D.

The number of tablets your doctor has recommended should be added to water.

  1. Remove the correct number of tablets from the foil.
If your child is only taking half a tablet at a time, place the remaining half of the tablet back in the foil and cover it up.
  1. Add half, one or two tablets as directed by your doctor, to water and mix well. At least a spoonful of water should be used.
  2. Wait about 30 or 40 seconds for the tablet to break down into fine granules. (The tablets will not completely dissolve). Stir if necessary.
  3. Ensure the water and granules are swallowed by your child straight away, otherwise the pleasant strawberry taste of Rulide D may disappear.
  4. Have a glass of water ready and giver your child a drink immediately after taking the medicine to ensure all the Rulide D is swallowed.

When and how long to take it

Rulide D works best on an empty stomach so it should be taken at least 15 minutes before food or at least 3 hours after a meal.

Rulide D is usually taken for 5 to 10 days. Children should not take Rulide D for more than 10 days.

Ask your doctor if you are not sure how long your child should be taking it.

Make sure your child takes Rulide D for the number of days your doctor has prescribed, even if they begin to feel better after a few days. If the full course is not finished, the infection may not clear completely or their symptoms may return.

If you forget to give a dose

Only give a missed dose if you remember it soon after the dose was due. Otherwise skip this dose altogether and go back to giving the medicine as you would normally.

Do not take a double dose to make up for the dose that was missed.

If you are not sure what to do, ask your doctor or pharmacist.

If you take too much (overdose)

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

While using Rulide D

Things you must do

If symptoms of your child's infection do not improve with a few days, or if they become worse, tell your doctor.

If your child is about to start taking any new medicine, tell your doctor or pharmacist that they are taking Rulide D.

Things you must not do

Rulide D has been prescribed for your child. Do not give to anyone else, even if they have the same condition as your child. Do not use Rulide D to treat any other complaints unless your doctor tells you to.

Side effects

Inform your doctor as soon as possible if your child has any problems while taking Rulide D, even if you do not think the problems are connected with the medicine or they are not listed in this leaflet.

Like other medicines, Rulide D can cause some side effects. If they occur, most are likely to be minor and temporary. However, some may be serious and need medical attention.

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

  • oral thrush - white, furry, sore tongue and mouth
  • vaginal thrush - sore and itch vagina and/or discharge
  • nausea, vomiting, stomach pain, indigestion, diarrhoea, loss of appetite, flatulence
  • rash
  • red and/or itchy skin
  • headache, dizziness, ringing in the ears
  • hallucinations
  • confusion
  • tiredness
  • altered taste
  • blurred vision and/or visual impairment

If any of the following happen, tell your doctor or pharmacist immediately or go to the Accident and Emergency Department at your nearest hospital:

  • frequent infections such as fever, severe chills, sore throat or mouth ulcers
  • severe persistent diarrhoea
  • an allergic reaction (for example, itchy skin, rash, swelling, asthma or wheezing)
  • swelling of the face lips mouth and tongue which may cause difficulty in swallowing or breathing
  • Severe blisters and bleeding in the lips, eyes, mouth, nose and genitals
  • severe skin rash

These may be serious side effects or signs of a serious allergic reaction.

Tell your doctor immediately if you notice any of the following symptoms, particularly if they occur within several weeks of stopping treatment with Rulide D:

  • severe abdominal cramps or stomach cramps
  • watery and severe diarrhoea, which may sometimes be bloody
  • fever, in combination with one or both of the above

These are rare but serious side effects. Your child may have a serious condition affecting the bowel. Therefore, your child may need urgent medical attention.

Do not be alarmed by this list of possible side effects. Your child may not experience any of them.

Other side effects not listed above may occur.

Tell your doctor or pharmacist if you notice anything else that is making your child feel unwell. Other side effects not listed above may occur.

After taking Rulide D

Tell your doctor immediately if you notice any of the following symptoms, particularly if they occur within several weeks of stopping treatment with Rulide D:

  • severe stomach cramps, diarrhoea with or without fever.

Do not give your child any diarrhoea medicine without first checking with your doctor.

Storage

Keep the tablets in the foil until it is time to take them.

Keep the tablets in a cool dry place where the temperature stays below 30°C.

Do not store Rulide D or any other medicine in the bathroom or near a sink.

Do not leave it in the car on hot days or on window sills. 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 or pharmacist tells you to stop giving Rulide D to your child, or the medicine has passed its expiry date, ask your pharmacist what to do with any that are left over.

Return any unused medicine to your pharmacist.

Product description

What it looks like

Rulide D are round, off-white, scored tablets. Each foil strip contains 10 tablets.

Ingredients

Active Ingredients

Each Rulide D tablets contains 50 mg of the active ingredient roxithromycin.

Inactive ingredients

Each tablet also contains:

  • microcrystalline cellulose -
  • fumaric acid
  • methacrylic acid copolymer
  • crospovidone
  • macrogol 6000
  • purified talc
  • saccharin sodium
  • colloidal anhydrous silica
  • magnesium stearate
  • triethyl citrate
  • sodium lauryl sulfate
  • sodium hydroxide
  • Strawberry Flavour Dry 995/2L 1/1000 Essepi
  • Liquorice Flavour Atomized

Manufacturer/Supplier

sanofi-aventis australia pty ltd
12-24 Talavera Road
Macquarie Park NSW 2113
Freecall No: 1800 818 806

Australian Registration Number:

AUST R 54811

Date of preparation: April 2020

rulide-d-ccdsv7-cmiv10-d1-an-29apr20

Published by MIMS June 2020

BRAND INFORMATION

Brand name

Rulide and Rulide D

Active ingredient

Roxithromycin

Schedule

S4

 

Name of the medicine

Roxithromycin.

Excipients.

Rulide.

Hyprolose, poloxamer, povidone, colloidal anhydrous silica, magnesium stearate (470), purified talc (553), maize starch, hypromellose, glucose, titanium dioxide (171) and propylene glycol (1520).

Rulide D.

Microcrystalline cellulose, crospovidone, magnesium stearate, fumaric acid, colloidal anhydrous silica, sodium saccharin, methacrylic acid copolymer, sodium hydroxide, purified talc, sodium lauryl sulfate, Macrogol 6000, triethyl citrate and liquorice and strawberry flavours.

Description

Molecular formula: C41H76N2O15. MW: 837.07. CAS: 80214-83-1. Roxithromycin is a semi-synthetic macrolide antibiotic. It is a white crystalline powder. Roxithromycin is very slightly soluble in water, freely soluble in acetone, in alcohol and in methylene chloride. It is slightly soluble in dilute hydrochloric acid.
Rulide tablets contain 150 mg or 300 mg of roxithromycin. Rulide D tablets contain 50 mg of roxithromycin.
Rulide tablets also contain hyprolose, poloxamer, povidone, colloidal anhydrous silica, magnesium stearate (470), purified talc (553), maize starch, hypromellose, glucose, titanium dioxide (171) and propylene glycol (1520).
Rulide D tablets also contain microcrystalline cellulose, crospovidone, magnesium stearate, fumaric acid, colloidal anhydrous silica, sodium saccharin, methacrylic acid copolymer, sodium hydroxide, purified talc, sodium lauryl sulfate, Macrogol 6000, triethyl citrate and liquorice and strawberry flavours.

Pharmacology

Pharmacokinetics.

Absorption.

Roxithromycin is absorbed after oral administration with an absolute bioavailability of approximately 50%. Peak plasma concentrations following administration of 150 and 300 mg film coated tablets are achieved in young and elderly adult patients approximately 1 to 2 hours postdose. However, Rulide D 50 mg tablets for suspension appear to be absorbed more slowly than the Rulide film coated tablets, with peak plasma concentrations achieved approximately 3 hours postdose.
As food intake decreases absorption, Rulide should be administered at least 15 minutes before food or, alternatively, on an empty stomach (i.e. more than 3 hours after a meal).
Absorption is not linear; with increasing doses in the range 150 mg to 300 mg, peak plasma levels and area under the curve (AUC) do not increase in proportion to the dose.
After repeated administration of 2.5 mg/kg every 12 hours to children, the average peak plasma concentration at steady state was 9 mg/L and the AUC was 61 mg.h/L.
Following administration of a single oral dose of Rulide 150 mg to healthy young adults, the mean peak plasma concentration was 6.6 mg/L and the AUC was 69 mg.h/L. At steady state following doses of 150 mg twice daily, the mean peak plasma concentration was 9.3 mg/L and the AUC was 71 mg.h/L.
In elderly patients, the mean peak plasma concentration following a single 150 mg dose was 9.1 mg/L and the AUC was 148 mg.h/L. At steady state, a dosage regimen of 150 mg twice daily produced a mean peak plasma concentration of 11.3 mg/L and an AUC of 83 mg.h/L.
Following administration of a single oral dose of Rulide 300 mg to healthy young adults, the mean peak plasma concentration was 9.7 mg/L and the AUC was 98 mg.h/L. At steady state following doses of 300 mg once daily, the mean peak plasma concentration was 10.9 mg/L and the AUC was 77 mg.h/L.
In elderly patients, the mean peak plasma concentration following a single 300 mg dose was 10.8 mg/L and the AUC was 197 mg.h/L.

Distribution.

Roxithromycin is 92-96% bound to plasma proteins (principally α1-acid glycoprotein, but also albumin) at concentrations less than 4.2 mg/L. The binding is saturable; in subjects with normal plasma levels of α1-acid glycoprotein, the extent of binding decreases when plasma concentrations of roxithromycin exceed 4.2 mg/L. At a plasma concentration of 8.4 mg/L, approximately 87% of the drug is protein bound.
Roxithromycin is highly concentrated in polymorphonuclear leucocytes and macrophages, where levels 30 times those in serum have been reported.

Elimination.

The mean half-life of roxithromycin is approximately 12 hours in young adults and 20 hours in children. The apparently longer half-life in children does not cause excessive accumulation: Cmin and AUC values are comparable for adults and children.
The half-life is prolonged to 25 hours in adults with impaired hepatic function and 18 hours in adults with renal insufficiency.
The mean half-life in elderly patients is approximately 27 hours.

Metabolism.

Roxithromycin undergoes limited metabolism in the body, presumably in the liver. The major metabolite is descladinose roxithromycin. Two minor metabolites have also been identified. Plasma levels of roxithromycin are approximately twice those of all metabolites; a similar ratio is seen in the urine and faeces.
Approximately 7% of a dose is excreted in the urine and 13% is eliminated via the lungs. Faecal excretion, which represents the unabsorbed fraction and the small proportion excreted by the liver, accounts for approximately 53% of the dose. The fate of the remainder is unknown.
When roxithromycin plasma levels are above 4.2 mg/L, renal clearance increases because reduced plasma protein binding (see Distribution) causes increased levels of unbound roxithromycin, which may be excreted by the kidneys.

Microbiology.

Roxithromycin is bacteriostatic at low concentrations and bactericidal at high concentrations. It binds to the 50S subunit of the 70S ribosome, thereby disrupting bacterial protein synthesis.
A prolonged postantibiotic effect has been observed with roxithromycin. Whilst the clinical significance of this remains uncertain, it supports the rationale for once daily dosing. Although clinical data have demonstrated the efficacy and safety of once daily dosing in adults, these have not been demonstrated in children.
At plasma concentrations achieved with the recommended therapeutic doses, roxithromycin has been demonstrated to have in vitro and clinical activity against the following microorganisms: Streptococcus pneumoniae, Streptococcus pyogenes, Mycoplasma pneumoniae, Moraxella catarrhalis, Ureaplasma urealyticum and Chlamydia spp.
Roxithromycin has been demonstrated to have clinical activity against the following microorganisms which are partially sensitive in vitro to roxithromycin: Haemophilus influenzae and Staphylococcus aureus, (except MRSA).
The following strains of microorganisms are resistant: multiresistant Staphylococcus aureus, Enterobacteriaceae, Pseudomonas sp. and Acinetobacter spp.

Susceptibility tests.

Dilution or diffusion techniques, either quantitative (MIC) or breakpoint, should be used following a regularly updated, recognised and standardised method (e.g. NCCLS). Standardised susceptibility test procedures require the use of laboratory control microorganisms to control the technical aspects of the laboratory procedures.
A report of susceptible indicates that the pathogen is likely to be inhibited if the antimicrobial compound in the blood reaches the concentrations usually achievable. A report of intermediate indicates that the result should be considered equivocal, and if the microorganism is not fully susceptible to alternative, clinically feasible drugs, the test should be repeated. This category implies possible clinical applicability in body sites where the drug is physiologically concentrated or in situations where high dosage of drug can be used. This category also provides a buffer zone, which prevents small uncontrolled technical factors from causing major discrepancies in interpretation. A report of resistant indicates that the pathogen is not likely to be inhibited if the antimicrobial compound in the blood reaches the concentrations usually achievable; other therapy should be selected.

Note.

The prevalence of resistance may vary geographically for selected species and local information on resistance is desirable, particularly when treating severe infections.
Using the NCCLS method of susceptibility testing with a roxithromycin 15 microgram disc, susceptible organisms other than Haemophilus influenzae produce zones of inhibition of diameter 21 mm or greater. A zone diameter of 10 to 20 mm should be considered intermediate and a zone diameter of 9 mm or less indicates resistance. A bacterial isolate may be considered susceptible if the MIC value for roxithromycin is less than or equal to 1 mg/L. Organisms are considered resistant if the MIC value is greater than 8 mg/L.
For Haemophilus influenzae, zones of inhibition of diameter 10 mm or greater indicate susceptibility when CO2 incubation and the HTM agar is used with a roxithromycin 15 microgram disc. An isolate may be considered susceptible if the MIC value for roxithromycin is less than or equal to 8 mg/L.

Indications

Adults.

Rulide is indicated for the treatment of the following types of mild to moderately severe infections in adults caused by or likely to be caused by susceptible microorganisms.
Upper respiratory tract infections: acute pharyngitis, tonsillitis and sinusitis.
Lower respiratory tract infections: acute bronchitis and acute exacerbations of chronic bronchitis; community acquired pneumonia.
Skin and skin structure infections.
Nongonococcal urethritis.

Children.

Rulide D 50 mg tablets and Rulide 150 mg tablets are indicated for the treatment of the following mild to moderately severe infections in children caused by or likely to be caused by susceptible microorganisms.
Acute pharyngitis.
Acute tonsillitis.
Impetigo.
Appropriate culture and sensitivity tests should be performed when necessary to determine organism susceptibility and thus treatment suitability. Therapy with roxithromycin may be initiated before results of these tests are known; once results become available, appropriate therapy should be continued.

Contraindications

Known hypersensitivity to macrolides, including erythromycin.
Severely impaired hepatic function (see Precautions).
Concomitant therapy with vasoconstrictive ergot alkaloids (see Interactions with Other Medicines).

Precautions

The safety of roxithromycin has not been demonstrated in patients with impaired hepatic or renal function. Caution should be exercised if roxithromycin is administered to patients with impaired hepatic or renal function. If administered to patients with severe impaired hepatic function (e.g. hepatic cirrhosis with jaundice and/or ascites), the dose should be reduced by half.
Renal excretion of roxithromycin and its metabolites accounts for a small percentage of an oral dose. The dosage should be kept unchanged in renal insufficiency.
Prolonged or repeated use of antibiotics including roxithromycin may result in superinfection by resistant organisms. In the event of superinfection, roxithromycin should be discontinued and appropriate therapy instituted.
When indicated, incision, drainage or other appropriate surgical procedures should be performed in conjunction with antibiotic therapy.
Antibiotic associated pseudomembranous colitis has been reported with many antibiotics. A toxin produced by Clostridium difficile appears to be the primary cause. The severity of the colitis may range from mild to life threatening. It is important to consider this diagnosis in patients who develop diarrhoea or colitis in association with antibiotic use (this may occur up to several weeks after cessation of antibiotic therapy). Mild cases usually respond to drug discontinuation alone. However, in moderate to severe cases, appropriate therapy with a suitable oral antibacterial agent effective against Clostridium difficile should be considered. Fluids, electrolytes and protein replacement therapy should be provided when indicated.
Drugs which delay peristalsis, e.g. opiates and diphenoxylate with atropine (Lomotil), may prolong and/or worsen the condition and should not be used.
Roxithromycin, like erythromycin, has been shown in vitro to elicit a concentration-dependent lengthening in cardiac action potential duration. Such an effect is manifested only at supra-therapeutic concentrations. Accordingly, the recommended doses should not be exceeded.
In certain conditions macrolides, including roxithromycin, have the potential to prolong the QT interval. Therefore roxithromycin should be used with caution in patients with congenital prolongation of the QT interval, with ongoing proarrhythmic conditions (i.e. uncorrected hypokalemia or hypomagnesaemia, clinically significant bradycardia), and in patients receiving Class IA and III antiarrhythmic agents and drugs such as astemizole, cisapride or pimozide (see Interactions with Other Medicines).
As with other macrolides, roxithromycin may have the potential to aggravate myasthenia gravis.

Clostridium difficile-associated disease.

Diarrhoea, particularly if severe, persistent and/or bloody, during or after treatment with roxithromycin, may be symptomatic of pseudomembranous colitis (see Adverse Effects). If pseudomembranous colitis is suspected, roxithromycin must be stopped immediately.
Cases of severe bullous skin reactions such as Stevens Johnson Syndrome or Toxic Epidermal Necrosis have been reported with roxithromycin (see Adverse Effects). If symptoms or signs of SJS or TEN (e.g. progressive skin rash often with blisters or mucosal lesions) are present, roxithromycin treatment should be discontinued.
Severe vasoconstriction (ergotism) with possibly necrosis of the extremities has been reported when macrolides antibiotics have been associated with vasoconstrictive ergot alkaloids. Absence of treatment by these alkaloids must always be checked before prescribing roxithromycin.

Use in children.

In young animal studies, high oral doses of roxithromycin were associated with bone growth plate abnormalities. However no abnormalities were observed in the animals at doses resulting in unbound plasma roxithromycin concentrations that were 10 to 15 times higher than the unbound concentration measured in children receiving the therapeutic dose. The maintenance of such safety margins is primarily dependent on high affinity binding of roxithromycin to plasma alpha-1-acid glycoprotein and will be compromised by any circumstances attenuating the extent of this binding. It is recommended that the approved paediatric dosage regimen (i.e. 5 to 8 mg/kg/day for a maximum of 10 days) be adhered to strictly.
Neutropenia was observed in children treated with roxithromycin. 31.6% of 402 children in clinical trials had a neutrophil count below the lower limit of the normal range (3500/mm3) at the conclusion of therapy with roxithromycin. Of these, 4% had a neutrophil count of less than 1500/mm3 and 1.2% had a count of less than 1000/mm3. It is not known whether this is an effect of the drug or whether it reflects a normal fluctuation of the neutrophil count or a response to infection in children.

Use in pregnancy.

(Category B1)
Reproductive studies in rats, mice and rabbits at doses of 100, 400 and 135 mg/kg/day, respectively, did not demonstrate evidence of developmental abnormalities. In rats, at doses above 180 mg/kg/day, there was evidence of embryotoxicity and maternotoxicity. The safety of roxithromycin for the human foetus has not been established.

Use in lactation.

Small amounts of roxithromycin are excreted in the breast milk. Breast feeding or treatment of the mother should be discontinued as necessary.

Use in elderly.

No dosage adjustment is required in elderly patients.

Carcinogenesis, mutagenesis and effects on fertility.

Long term studies in animals have not been performed to evaluate the carcinogenic potential of roxithromycin. Roxithromycin has shown no mutagenic potential in standard laboratory tests for gene mutation and chromosomal damage.
There was no effect on the fertility of rats treated with roxithromycin at oral doses up to 180 mg/kg/day.

Effects on ability to drive and use machinery.

Attention should be drawn to the possibility of dizziness, visual impairment and blurred vision.

Interactions

Roxithromycin has a much lower affinity for cytochrome P450 than erythromycin and consequently has fewer interactions. Interactions may be observed, however, with drugs that bind to α1-acid glycoprotein, such as disopyramide.
Roxithromycin does not appear to interact with oral contraceptives containing oestrogens and progestogens, prednisolone, carbamazepine, ranitidine or antacids.

Theophylline.

A study in normal subjects concurrently administered roxithromycin and theophylline has shown some increase in the plasma concentration of the latter. While a change in dosage is usually not required, patients with high levels of theophylline at commencement of treatment should have levels monitored.

Ergot alkaloids.

Reactions of ergotism with possible peripheral necrosis have been reported after concomitant therapy of macrolides with vasoconstrictive ergot alkaloids, particularly ergotamine and dihydroergotamine. Because a clinical interaction with roxithromycin cannot be excluded, administration of roxithromycin to patients taking ergot alkaloids is contraindicated. Absence of treatment with these alkaloids must always be checked before prescribing roxithromycin.

Disopyramide.

An in vitro study has shown that roxithromycin can displace protein bound disopyramide; such an effect in vivo could result in increased serum levels of disopyramide. Consequently ECG and, if possible, disopyramide serum levels should be monitored.

Terfenadine.

Some macrolide antibiotics (e.g. erythromycin) may increase serum levels of terfenadine. This can result in severe cardiovascular adverse events, including QT prolongation, torsades de pointes and other ventricular arrhythmias. Such a reaction has not been documented with roxithromycin, which has a much lower affinity for cytochrome P450 than erythromycin. However, in the absence of a systematic interaction study, concomitant administration of roxithromycin and terfenadine is not recommended.

Astemizole, cisapride, pimozide.

Other drugs, such as astemizole, cisapride or pimozide, which are metabolized by the hepatic isozyme CYP3A4, have been associated with QT interval prolongation and/or cardiac arrhythmias (typically torsades de pointes) as a result of an increase in their serum level subsequent to interaction with significant inhibitors of this isozyme, including some macrolide antibacterials. Although roxithromycin has no or limited ability to complex CYP3A4 and therefore to inhibit the metabolism of other drugs processed by this isozyme, a potential for clinical interaction of roxithromycin with the abovementioned drugs cannot be either ascertained or ruled out in confidence; therefore, concomitant administration of roxithromycin and such drugs is not recommended.
Roxithromycin, like other macrolides, should be used with caution in patients receiving class IA and III antiarrhythmic agents (see Precautions).

Vitamin K antagonists.

While no interaction was observed in volunteer studies, roxithromycin appears to interact with warfarin. Increases in prothrombin time (international normalised ratio (INR)) have been reported in patients treated concomitantly with roxithromycin and warfarin or the related vitamin K antagonist phenprocoumon, and severe bleeding episodes have occurred as a consequence. INR should be monitored during combined treatment with roxithromycin and vitamin K antagonists.

Digoxin and other cardiac glycosides.

A study in healthy volunteers has shown that roxithromycin may increase the absorption of digoxin. This effect, common to other macrolides, may very rarely result in cardiac glycoside toxicity. This may be manifested by symptoms, such as nausea, vomiting, diarrhoea, headache or dizziness; cardiac glycoside toxicity may also elicit heart conduction and/or rhythm disorders. Consequently, in patients treated with roxithromycin and digoxin or another cardiac glycoside, ECG and, if possible, the serum level of the cardiac glycoside should be monitored; this is mandatory if symptoms which may suggest cardiac glycoside overdosage occur.

Midazolam.

Roxithromycin, like other macrolides, may increase the area under the midazolam concentration time curve and the midazolam half-life, therefore, the effects of midazolam may be enhanced and prolonged in patients treated with roxithromycin. There is no conclusive evidence for an interaction between roxithromycin and triazolam.

Theophylline and ciclosporin.

A slight increase in plasma concentrations of theophylline or ciclosporin A has been observed. This does not generally necessitate altering the usual dosage.

CYP3A.

Roxithromycin is a weak CYP3A inhibitor. The effect of roxithromycin on exposure to drugs predominantly cleared by CYP3A metabolism would be expected to be 2-fold or less. Caution should be exercised when roxithromycin is concomitantly prescribed with drugs metabolised by CYP3A (such as rifabutin and bromocriptine).

Adverse Effects

Roxithromycin is generally well tolerated. In clinical trials, treatment discontinuation due to adverse effects occurred in only 1.2% of adult patients and 1.0% of children. The following side-effects or serious adverse events possibly associated with roxithromycin have been reported.

Gastrointestinal.

Nausea, vomiting, epigastric pain (dyspepsia), diarrhoea (sometimes containing blood), anorexia, flatulence, pseudomembranous colitis. In clinical studies, the incidence of gastrointestinal events was higher with the 300 mg once daily dosage regimen than with 150 mg twice daily. Symptoms of pancreatitis have been observed; most patients had received other drugs for which pancreatitis is a known adverse effect.

Hypersensitivity.

Urticaria, rash, pruritus, angioedema. Rarely, serious allergic reactions may occur such as asthma, bronchospasm, anaphylactic-like reactions, anaphylactic shock, purpura, glottic oedema, generalised oedema, erythema multiforme, exfoliative dermatitis, acute generalised exanthematous pustulosis (AGEP), Stevens-Johnson Syndrome and Toxic Epidermal Necrosis (TEN) (see Precautions).

Liver.

Moderate increase in serum transaminases, AST-ALT and/or alkaline phosphatase levels have been observed and are somewhat more likely to occur in the elderly (> 65 years of age). Acute cholestatic hepatitis and acute hepatocellular injury (sometimes with jaundice), are rarely reported.

Others.

Eosinophilia, agranulocytosis, neutropenia, thrombocytopenia, bronchospasm, hallucination, confusion, headache, dizziness, paraesthesia, tinnitus, malaise, moniliasis, pancreatitis, QT prolongation, disorders of taste and/or smell, visual impairment, blurred vision, temporary deafness, hypoacusis and vertigo.
Prolonged use of antibiotics including roxithromycin may result in superinfection; overgrowth of non-susceptible organisms. Repeated evaluation of the patient’s condition is essential. In the event of superinfection, appropriate measures should be taken.

Dosage and Administration

Adults.

Rulide should be taken at least 15 minutes before food or on an empty stomach (i.e. more than 3 hours after a meal).
The recommended dosage is 300 mg per day which may be taken according to one of the following alternative dosage regimens.

Usual dosage.

Rulide 300 mg tablets: one tablet daily; Rulide 150 mg tablets: one tablet twice daily or two tablets once daily.

Elderly.

Rulide 300 mg tablets: one tablet daily; Rulide 150 mg tablets: one tablet twice daily or two tablets once daily.

Impaired renal function.

Rulide 300 mg tablets: one tablet daily; Rulide 150 mg tablets: one tablet twice daily or two tablets once daily.
For atypical pneumonia, the recommended dosage is 150 mg twice daily.
Rulide 150 mg and 300 mg film coated tablets must be swallowed whole with a drink.
The usual duration of treatment is 5 to 10 days depending on the indication and clinical response. Streptococcal throat infections require at least 10 days of therapy. A small proportion of patients with nongonococcal genital infections may require 20 days for complete cure.

Children.

The recommended dose and duration of treatment should not be exceeded in children (see Precautions).
Rulide should be taken at least 15 minutes before food or on an empty stomach (i.e. more than 3 hours after a meal).
Rulide is administered twice daily at a dose of 5 to 8 mg/kg/day. Recommended dosage regimens are as follows.

Bodyweight 6 to 11 kg.

Half a Rulide D 50 mg tablet morning and evening.

Bodyweight 12 to 23 kg.

One Rulide D 50 mg tablet morning and evening.

Bodyweight 24 to 40 kg.

Two Rulide D 50 mg tablets morning and evening.

Bodyweight > 40 kg.

One Rulide 150 mg tablet morning and evening.
Rulide D 50 mg tablets are administered to children weighing less than 40 kg as an aqueous suspension that is made by adding either a half, one or two tablets to a spoonful of water. After waiting 30 to 40 seconds for the tablet(s) to disintegrate into fine granules, the suspension is given to the child. A drink of water should follow the dose.

Note.

Only Rulide D 50 mg tablets are designed to be mixed with water. The 150 mg and 300 mg film coated tablets must be swallowed whole with a drink.
The usual duration of treatment is 5 to 10 days depending on the indication and clinical response. Streptococcal throat infections require 10 days of therapy. The duration of treatment should not exceed 10 days.

Overdosage

Symptomatic treatment should be provided as required. There is no specific antidote.
For information on the management of overdose, contact the Poisons Information Centre on 131 126 (Australia).

Presentation

Rulide.

Tablets (white, cylindrical, biconvex, film coated), 150 mg (9 mm diameter, marked 164 on one side): 10's (blister pack); 300 mg (11 mm diameter, marked 164J on one side): 5's (blister pack).

Rulide D.

Tablets for suspension, 50 mg (practically white, cylindrical, 8 mm diameter, scored): 10's (aluminium blister pack).

Storage

Rulide 150 mg.

Store in a cool dry place below 25°C.

Rulide 300 mg.

Store in a cool dry place below 30°C.

Rulide D.

Store in a cool place below 30°C.

Poison Schedule

S4.