Source: Medicines & Healthcare Products Regulatory Agency (GB) Revision Year: 2014 Publisher: Dexcel-Pharma Ltd., 7 Sopwith Way, Drayton Fields, Daventry, Northamptonshire, NN11 8PB, UK
Hypersensitivity to minocycline or to any other of the tetracyclines or to any of the capsule excipients.
Pregnancy and lactation.
Children of less than 12 years of age.
Renal failure.
Minocycline should be used with caution in patients with hepatic dysfunction and in conjunction with alcohol and other hepatotoxic drugs. It is recommended that alcohol consumption should remain within the Government’s recommended limits.
Rare cases of auto-immune hepatotoxicity, isolated cases of systemic lupus erythematosus (SLE) and exacerbation of pre-existing SLE have been reported. If patients develop signs or symptoms of SLE or hepatotoxicity, or suffer exacerbation of pre-existing SLE, minocycline should be discontinued.
The anti-anabolic action of the tetracyclines may cause an increase in serum urea. In patients with significantly impaired renal function, higher serum levels of tetracyclines may lead to uraemia, hyperphosphataemia and acidosis. If renal impairment exists, even usual oral and parenteral doses may lead to excessive systemic accumulations of the drug and possible liver toxicity.
Minocycline is contraindicated in persons with renal failure. Clinical studies have shown that there is no significant drug accumulation in patients with lesser degrees of renal impairment when they are treated with minocycline in the recommended doses. In the more severe cases of renal insufficiency, reduction of dosage and monitoring of renal function may be required.
Caution is advised in patients with myasthenia gravis as tetracyclines can cause weak neuromuscular blockade.
Cross-hypersensitivity between tetracyclines may occur in patients (see section 4.3).
Cross-resistance between tetracyclines may develop in micro-organisms and cross-sensitisation in patients. Minocycline should be discontinued if there are signs/symptoms of overgrowth of resistant organisms, e.g. enteritis, glossitis, stomatitis, vaginitis, pruritus and or Staphylococcal enteritis.
Patients taking oral contraceptives should be warned that if diarrhoea or breakthrough bleeding occur there is a possibility of contraceptive failure.
Minocycline may cause hyperpigmentation at various body sites (see section 4.8). Hyperpigmentation may present regardless of dose or duration of therapy but develops more commonly during long term treatment. Patients should be advised to report any unusual pigmentation without delay and Minocycline should be discontinued.
If a photosensitivity reaction occurs (see section 4.8), patients should be warned to avoid direct exposure to natural or artificial light and to discontinue therapy at the first signs of skin discomfort.
As with other tetracyclines, bulging fontanelles in infants and benign intracranial hypertension in juveniles and adults have been reported. Presenting features were headache and visual disturbances including blurring of vision, scotoma and diplopia. Permanent vision loss has been reported. Treatment should cease if evidence of raised intracranial pressure develops.
Dose selection for an elderly patient should be cautious, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.
Minocycline is contraindicated in children of less than 12 years of age. The use of tetracyclines during tooth development in children under the age of 12 years may cause permanent discoloration. Enamel hypoplasia has also been reported.
Periodic laboratory evaluations of organ system function, including haematopoietic, renal and hepatic should be conducted.
Tetracyclines depress plasma prothrombin activity and reduced doses of concomitant anticoagulants may be necessary.
Diuretics may aggravate nephrotoxicity by volume depletion.
Minocycline should not be used with beta-lactam antibacterial agents due to the possibility of antagonism.
Bacteriostatic drugs may interfere with the bactericidal action of penicillin. Avoid giving tetracycline-class drugs in conjunction with penicillin. Absorption of minocycline is impaired by the concomitant administration of antacids, iron, calcium, magnesium, aluminium, bismuth and zinc salts (interactions with specific salts, antacids, bismuth containing ulcer – healing drugs, quinapril which contains a magnesium carbonate excipient). It is recommended that any indigestion remedies, vitamins, or other products that contain these salts should be are taken at least 3 hours before or after a dose of Minocycline. However, the absorption of minocycline is not significantly impaired by food or moderate amounts of milk.
There is an increased risk of ergotism when ergot alkaloids or their derivatives are given with tetracyclines.
The concomitant use of tetracyclines may reduce the efficacy of oral contraceptives.
Administration of isotretinoin or other systemic retinoids or retinol should be avoided shortly before, during and shortly after minocycline therapy. Each of these agents alone has been associated with pseudotumor cerebri (benign intracranial hypertension) (see section 4.4 and 4.8).
Interference with laboratory and other diagnostic tests:
False elevations of urinary catecholamine levels may occur due to interference with the fluorescence test.
Minocycline is contraindicated in pregnancy.
Results of animal studies indicate that tetracyclines cross the placenta, are found in foetal tissues and can have toxic effects on the developing foetus (often related to retardation of skeletal development). Evidence of embryotoxicity has also been noted in animals treated early in pregnancy. Minocycline therefore, should not be used in pregnancy unless considered essential.
In humans, minocycline, like other tetracycline-class antibiotics, crosses the placenta and may cause foetal harm when administered to a pregnant woman. In addition, there have been post marketing reports of congenital abnormalities including limb reduction. If minocycline is used during pregnancy or if the patient becomes pregnant while taking this drug, the patient should be informed of the potential hazard to the foetus.
The use of drugs of the tetracycline class during tooth development (last half of pregnancy) may cause permanent discoloration of the teeth (yellow-grey-brown). This adverse reaction is more common during long term use of the drugs but has been observed following repeated short term courses. Enamel hypoplasia has also been reported.
Tetracyclines administered during the last trimester form a stable calcium complex throughout the human skeleton. A decrease in fibula growth rate has been observed in premature human infants given oral tetracyclines in doses up to 25mg/kg every 6 hours. Changes in fibula growth rate were shown to be reversible when the drug was discontinued.
Minocycline is contraindicated during lactation.
Tetracyclines have been found in the milk of lactating women who are taking a drug in this class. Permanent tooth discoloration may occur in the developing infant and enamel hypoplasia has been reported.
Headache, light-headedness, dizziness, tinnitus and vertigo (more common in women) and, rarely, impaired hearing have occurred with minocycline. Patients should be warned about the possible hazards of driving or operating machinery during treatment. These symptoms may disappear during therapy and usually disappear when the drug is discontinued.
Adverse reactions are listed in the Table in CIOMS frequency categories under MedDRA system/organ classes: Common ≥1%, Uncommon ≥0.1% and <1%, Rare ≥0.01% and <0.1%, Very Rare <0.01%.
Very Rare: Oral and anogenital candidiasis, vulvovaginitis.
Rare: Eosinophilia, leucopenia, neutropenia, thrombocytopenia.
Very Rare: Haemolytic anaemia, pancytopenia.
There are also reports of: Agranulocytosis.
__Rare: Anaphylaxis/anaphylactoid reaction (including shock), including fatalities.
There are also reports of: Hypersensitivity, pulmonary infiltrates, anaphylactoid purpura.
Very Rare: Abnormal thyroid function, brown-black discolouration of the thyroid.
Rare: Anorexia.
Common: Dizziness (lightheadedness).
Rare: Headache, hypaesthesia, paraesthesia, intracranial hypertension, vertigo.
Very Rare: Bulging fontanelle.
There are also reports of: convulsions, sedation.
Rare: Impaired hearing, tinnitus.
Rare: Myocarditis, pericarditis.
Rare: Cough, dyspnoea.
Very Rare: Bronchospasm, exacerbation of asthma, pulmonary eosinophilia.
There are also reports of: Pneumonitis.
Rare: Diarrhoea, nausea, stomatitis, discolouration of teeth including adult tooth discolouration, vomiting.
Very Rare: Dyspepsia, dysphagia, enamel hypoplasia, enterocolitis, oesophagitis, oesophageal ulceration, glossitis, pancreatitis, pseudomembranous colitis.
There are also reports of: Oral cavity discolouration (including tongue, lip and gum).
Rare: Increased liver enzymes, hepatitis, autoimmune hepatoxicity. (See Section 4.4 Special warnings and precautions for use).
Very Rare: Hepatic cholestatis, hepatic failure (including fatalities), hyperbilirubinaemia, jaundice.
There are also reports of: Autoimmune hepatitis.
Rare: Alopecia, erythema multiforme, erythema nodosum, fixed drug eruption, hyperpigmentation of skin, photosensitivity, pruritis, rash, urticaria, vasculitis.
Very Rare: Angioedema, exfoliative dermatitis, hyperpigmentation of nails, Stevens-Johnson Syndrome, toxic epidermal necrolysis.
Rare: Arthralgia, lupus-like syndrome, myalgia.
Very Rare: Arthritis, bone discolouration, cases of or exacerbation of systemic lupus erythematosus (SLE) (See Section 4.4 Special warnings and Special precautions for use), joint stiffness, joint swelling.
Rare: Increased serum urea, acute renal failure, interstitial nephritis.
Very Rare: Balanitis.
Uncommon: Fever.
Very Rare: Discolouration of secretions.
The following syndromes have been reported. In some cases involving these syndromes, death has been reported. As with other serious adverse reactions, if any of these syndromes are recognised, the drug should be discontinued immediately:
Hyperpigmentation of various body sites including the skin, nails, teeth, oral mucosa, bones, thyroid, eyes (including sclera and conjunctiva), breast milk, lacrimal secretions and perspiration has been reported. This blue/black/grey or muddy-brown discolouration may be localised or diffuse. The most frequently reported site is in the skin. Pigmentation is often reversible on discontinuation of the drug, although it may take several months or may persist in some cases. The generalised muddy-brown skin pigmentation may persist, particularly in areas exposed to the sun.
Reporting suspected adverse reactions after authorisation 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 via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.
Not applicable.
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