Source: Medicines & Healthcare Products Regulatory Agency (GB) Revision Year: 2021 Publisher: MEDICE Arzneimittel Pütter GmbH & Co. KG, Kuhloweg 37, 58638 Iserlohn, Germany
Prior to prescribing, it is necessary to conduct a baseline evaluation of a patient’s cardiovascular status including blood pressure and heart rate. A comprehensive history should document concomitant medications, past and present co-morbid medical and psychiatric disorders or symptoms, family history of sudden cardiac/unexplained death and accurate recording of pre-treatment height and weight on a growth chart (see sections 4.3 and 4.4).
Growth, psychiatric and cardiovascular status should be continuously monitored (see also section 4.4).
Patients should be monitored for the risk of diversion, misuse, and abuse of dexamfetamine
The safety and efficacy of long-term use of dexamfetamine has not been systematically evaluated in controlled trials. Dexamfetamine treatment should not be and does not need to be indefinite. Dexamfetamine treatment is usually discontinued during or after puberty. Patients on long-term therapy (i.e. over 12 months) must have careful ongoing monitoring according to the guidance in sections 4.2 and 4.4 for cardiovascular status, growth, appetite, and development of de novo or worsening of pre-existing psychiatric disorders. Psychiatric disorders to monitor for are described below, and include (but are not limited to) motor or vocal tics, aggressive or hostile behaviour, agitation, anxiety, depression, psychosis, mania, delusions, irritability, lack of spontaneity, withdrawal, and excessive perseveration.
The physician who elects to use dexamfetamine for extended periods (over 12 months) in children and adolescents with ADHD should periodically re-evaluate the long-term usefulness of the medicinal product for the individual patient with trial periods off medication to assess the patient’s functioning without pharmacotherapy. It is recommended that dexamfetamine is de-challenged at least once yearly to assess the child’s condition (preferably during times of school holidays). Improvement may be sustained when the medicinal product is either temporarily or permanently discontinued.
Patients who are being considered for treatment with stimulant medications should have a careful history (including assessment for a family history of sudden cardiac or unexplained death or malignant arrhythmia) and physical exam to assess for the presence of cardiac disease, and should receive further specialist cardiac evaluation if initial findings suggest such history or disease. Patients who develop symptoms such as palpitations, exceptional chest pain, unexplained syncope, dyspnoea, or other symptoms suggestive of cardiac disease during dexamfetamine treatment should undergo a prompt specialist cardiac evaluation.
Cardiovascular status should be carefully monitored. Blood pressure and pulse should be recorded on a centile chart at each adjustment of dose and then at least every 6 months.
Treatment with stimulants in general may lead to a minor increase in blood pressure (approx. 2-4 mm Hg) as well as an increase in heart rate (approx. 3-6 beats/minute). In few patients, these values may be higher.
The short- and long-term clinical consequences of these cardiovascular effects in children and adolescents are not known, but the possibility of clinical complications cannot be excluded as a result of the effects observed in the clinical trial data. Caution is indicated in treating patients whose underlying medical conditions might be compromised by increases in blood pressure or heart rate. See section 4.3 for conditions in which dexamfetamine treatment in contraindicated.
The use of dexamfetamine is contraindicated in certain pre-existing cardiovascular disorders unless specialist paediatric cardiac advice has been obtained (see section 4.3).
Sudden death has been reported in association with the use of stimulants of the central nervous system at usual doses in children, some of whom had cardiac structural abnormalities or other serious heart problems. Although some serious heart problems alone may carry an increased risk of sudden death, stimulant products are not recommended in children or adolescents with known cardiac structural abnormalities, cardiomyopathy, serious heart rhythm abnormalities, or other serious cardiac problems that may place them at increased vulnerability to the onset of sympathomimetic effects of a stimulant medicine (see section 4.3).
Misuse of stimulants of the central nervous system may be associated with sudden death and other serious cardiovascular adverse events.
Cases of cardiomyopathy have been observed with chronic use of amfetamine.
See section 4.3 for cerebrovascular conditions in which dexamfetamine treatment is contraindicated. Patients with additional risk factors (such as a history of cardiovascular disease or concomitant medications that elevate blood pressure) should be assessed at every visit for neurological signs and symptoms after initiating treatment with dexamfetamine.
Cerebral vasculitis appears to be a very rare idiosyncratic reaction to dexamfetamine exposure. There is little evidence to suggest that patients at higher risk can be identified and the initial onset of symptoms may be the first indication of an underlying clinical problem. Early diagnosis, based on a high index of suspicion, may allow the prompt withdrawal of dexamfetamine and early treatment. The diagnosis should therefore be considered in any patient who develops new neurological symptoms that are consistent with cerebral ischemia during dexamfetamine therapy. These symptoms could include severe headache, numbness, weakness, paralysis, and impairment of coordination, vision, speech, language, or memory.
Treatment with dexamfetamine is not contraindicated in patients with hemiplegic cerebral palsy.
Comorbidity of psychiatric disorders in ADHD is common and should be taken into account when prescribing stimulant products. In the case of emergent psychiatric symptoms or exacerbation of pre-existing psychiatric disorders, dexamfetamine should not be given unless the benefits outweigh the risks to the patient.
Development or worsening of psychiatric disorders should be monitored at every adjustment of dose, then at least every 6 months, and at every visit; discontinuation of treatment may be appropriate.
Exacerbation of pre-existing psychotic or manic symptoms
In psychotic patients, administration of dexamfetamine may exacerbate symptoms of behavioural disturbance and thought disorder.
Treatment-emergent psychotic symptoms (visual/tactile/auditory hallucinations and delusions) or mania in children and adolescents without prior history of psychotic illness or mania can be caused by dexamfetamine at usual doses.
A pooled analysis of various short-term, placebo-controlled studies revealed that such symptoms occurred in approx. 0.1% of patients (4 out of 3,482) who were treated with dexamfetamine or amfetamine for several weeks, whereas none of the patients of the placebo group were affected by these symptoms.
If manic or psychotic symptoms occur, consideration should be given to a possible causal role for dexamfetamine, and discontinuation of treatment may be appropriate.
The emergence or worsening of aggression or hostility can be caused by treatment with stimulants. Patients treated with dexamfetamine should be closely monitored for the emergence or worsening of aggressive behaviour or hostility at treatment initiation, at every dose adjustment and then at least every 6 months and at every visit. Physicians should evaluate the need for adjustment of the treatment regimen in patients experiencing behaviour changes.
Patients with emergent suicidal ideation or behaviour during treatment for ADHD should be evaluated immediately by their physician. Consideration should be given to the exacerbation of an underlying psychiatric condition and to a possible causal role of dexamfetamine treatment. Treatment of an underlying psychiatric condition may be necessary and consideration should be given to a possible discontinuation of dexamfetamine.
Dexamfetamine is associated with the onset or exacerbation of motor and verbal tics. Worsening of Tourette’s syndrome has also been reported. Family history should be assessed and clinical evaluation for tics or Tourette’s syndrome in children should precede the use of dexamfetamine. Patients should be regularly monitored for the emergence or worsening of tics during treatment with dexamfetamine. Monitoring should be at every adjustment of dose and then at least every 6 months or every visit.
Dexamfetamine is associated with the worsening of pre-existing anxiety, agitation, or tension. Clinical evaluation for anxiety, agitation or tension should precede use of dexamfetamine and patients should be regularly monitored for the emergence or worsening of these symptoms during treatment, at every adjustment of dose and then at least every 6 month or at every visit.
Particular care should be taken in using dexamfetamine to treat ADHD in patients with comorbid bipolar disorder (including untreated type I bipolar disorder or other forms of bipolar disorder) because of concerns for possible precipitation of a mixed/manic episode in such patients. Prior to initiating treatment with dexamfetamine, patients with comorbid depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder. Such a screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression. Close ongoing monitoring is essential in these patients (see above ‘Psychiatric disorders’ and section 4.2). Patients should be monitored for symptoms at every adjustment of dose, then at least every 6 months and at every visit.
Moderately reduced weight gain and growth retardation have been reported with the long-term use of dexamfetamine in children.
The effects of dexamfetamine on final height and final weight are currently unknown and being studied.
Growth should be monitored during dexamfetamine treatment: height, weight and appetite should be recorded at least 6 monthly with maintenance of a growth chart. Patients who are not growing or gaining height or weight as expected may need to have their treatment interrupted.
As a reduction in appetite may occur during treatment with dexamfetamine, the medicinal product may only be administered with special caution to patients with Anorexia nervosa.
Dexamfetamine should be used with caution in patients with epilepsy. Dexamfetamine may lower the convulsive threshold in patients with prior history of seizures, in patients with prior EEG abnormalities in the absence of seizures, and rarely in patients without a history of convulsions and no EEG abnormalities. If seizure frequency increases or new-onset seizures occur, dexamfetamine should be discontinued.
Patients should be carefully monitored for the risk of diversion, misuse, and abuse of dexamfetamine.
The risk is generally greater for short acting stimulants than for corresponding long-acting products (see section 4.1).
Dexamfetamine should not be used in patients with known drug or alcohol dependency because of a potential for abuse, misuse, or diversion.
Chronic abuse of dexamfetamine can lead to marked tolerance and psychological dependence with varying degrees of abnormal behaviour. Frank psychotic episodes can occur, especially in response to parenteral abuse.
Signs of chronic amfetamine intoxication include severe dermatoses, pronounced sleeplessness, confusion, hyperactivity, and personality changes. The most severe sign of chronic amfetamine intoxication is a psychosis which in most cases can hardly be clinically distinguished from schizophrenia. However, such a psychosis rarely occurs after oral ingestion of amfetamines. There have also been reports of intracerebral bleeding. Serious cardiovascular events observed in association with amfetamine misuse were sudden death, cardiomyopathy, and myocardial infarction.
Patient age, the presence of risk factors for substance use disorder (such as comorbid oppositional-defiant or conduct disorder and bipolar disorder), previous or current substance abuse should all be taken into account when deciding on a course of treatment for ADHD. Caution is called for in emotionally unstable patients, such as those with a history of drug or alcohol dependence, because such patients may increase the dosage on their own initiative.
For some high-risk substance abuse patients, dexamfetamine or other stimulants may not be suitable. This may also be true for other stimulants and therefore, non-stimulant treatment should be considered.
Careful supervision is required during withdrawal of the medicinal product, since this may unmask depression as well as chronic over-activity. Some patients may require long-term follow up.
Similarly, careful supervision is required during withdrawal from abusive use since severe depression may occur.
Abrupt withdrawal after a prolonged period of intake of high doses of dexamfetamine may cause extreme fatigue as well as changes in the EEG during sleep.
Dexamfetamine should not be used for the prevention or treatment of normal fatigue states.
This product contains dexamfetamine which may induce a positive laboratory test for amfetamines, particularly with an immunoassay screening test.
Athletes must be aware that this medicinal product may cause a positive reaction to’anti-doping' tests.
There is no experience with the use of dexamfetamine in patients with renal or hepatic insufficiency. In those patients peak plasma levels could be higher and elimination could be prolonged. Thus, dexamfetamine should be used with special caution in this patient group by taking care of titration and dosage.
The long-term safety of treatment with dexamfetamine is not fully known. In the event of leukopenia, thrombocytopenia, anaemia, or other alterations, including those indicative of serious renal or hepatic disorders, discontinuation of treatment should be considered.
This medicinal product contains isomalt. Due to the presence of isomalt in the formulation, patients with rare hereditary problems of fructose intolerance should not take this medicine.
Because of possible hypertensive crisis, dexamfetamine is contraindicated in patients being treated (currently or within the preceding 2 weeks) with non-selective, irreversible MAO-inhibitors (see section 4.3).
It is not known whether dexamfetamine may inhibit or induce cytochrome P450 (CYP) enzymes. Co-administration of CYP substrates with narrow therapeutic index should therefore be made with caution.
It is not known to which degree dexamfetamine metabolism is dependent on CYP enzymes. Co-administration of potent inhibitors or inducers of CYP enzymes should be made with caution.
Gastrointestinal acidifying agents (guanethidine, reserpine, glutamic acid HCl, ascorbic acid, fruit juices, etc.) lower the absorption of amfetamines.
Urinary acidifying agents (ammonium chloride, sodium acid phosphate, etc.) increase the concentration of the ionized species of the amfetamine molecule, thereby increasing urinary excretion. Both groups of agents lower blood levels and efficacy of amfetamines.
Gastrointestinal alkalinizing agents (sodium bicarbonate, etc.) increase the absorption of amfetamines. Urinary alkalinizing agents (acetazolamide, some thiazides) increase the concentration of the non-ionized species of the amfetamine molecule, thereby decreasing urinary excretion. Both groups of agents increase blood levels and therefore potentiate the actions of amfetamines.
Concomitant administration of clonidine and dexamfetamine may result in an increased duration of the action of dexamfetamine.
Dexamfetamine may counteract the sedative effect of antihistamines.
Dexamfetamine may inhibit the antihypertensive action of guanethidine or clonidine. Concomitant use of beta-blockers may lead to severe hypertonia, as the therapeutic action of these agents may be inhibited by dexamfetamine.
Depressant effects of opiates, e.g. respiratory depression, may be decreased by dexamfetamine.
Halogenated narcotics: There is a risk of sudden blood pressure increase during surgery. If surgery is planned, dexamfetamine treatment should not be used on the day of surgery.
Concomitant use of tricyclic antidepressants may increase the risk of cardiovascular adverse events.
Because of a possible increase in blood pressure, special caution is advised if Amfexa 5 mg Tablets is administered to patients being treated with vasopressors (see also sections on cardiovascular and cerebrovascular conditions in section 4.4).
Dexamfetamine may enhance the adrenergic effect of noradrenaline.
Dexamfetamine may potentiate the analgesic effects of meperidine.
The analgesic action of morphine may be potentiated by the concomitant use of dexamfetamine,
There are reports indicating that dexamfetamine may inhibit the metabolism of coumarin anticoagulants, anticonvulsants (e.g. phenobarbital, phenytoin, and primidone) and some antidepressants (tricyclics and selective serotonin reuptake inhibitors). When starting or stopping treatment with dexamfetamine, it may be necessary to adjust the dosage of these medicinal products already being taken and establish drug plasma concentrations (or for coumarin, coagulation times).
Disulfiram may inhibit the metabolism and excretion of dexamfetamine.
Adrenergic blockers (e.g. propranolol), lithium, and α-methyltyrosine may attenuate the effects of dexamfetamine.
Concomitant use of haloperidol may inhibit the central stimulant effects of dexamfetamine. Acute dystonia has been noted with concurrent administration of haloperidol.
The absorption of anticonvulsants (e.g. phenobarbital, phenytoin, primidone, and ethosuximide) may be delayed by dexamfetamine.
Alcohol may exacerbate the CNS adverse reactions of psychoactive medicinal products, including dexamfetamine. It is therefore advisable for patients to abstain from alcohol during treatment.
Phenothiazines, e.g. chlorpromazine block dopamine receptors, thus inhibiting the central stimulant effects of amfetamines, and can be used to treat amfetamine poisoning.
Data from a cohort study of in total approximately 5570 pregnancies exposed to amfetamine in the first trimester do not suggest an increased risk of congenital malformation. Data from another cohort study in approximately 3100 pregnancies exposed to amfetamine during the first 20 weeks of pregnancy, suggest an increased risk of preeclampsia, and preterm birth.
Children of mothers who are dependent on amfetamine have been shown to be at an increased risk of premature birth and reduced birth weight.
Moreover, these children may develop withdrawal symptoms like dysphoria, including hyperexcitability and pronounced exhaustion.
Results of studies in animals suggest that high doses of dexamfetamine may elicit reproductive toxicity (see section 5.3). The use of Amfexa 5 mg Tablets during pregnancy is not recommended. Women of childbearing age should discontinue the use of Amfexa 5 mg Tablets when intending to become pregnant.
Dexamfetamine is excreted in human milk. A risk to the newborns/infants cannot be excluded.
A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from Amfexa 5 mg Tablets therapy taking into account the benefit of breast feeding for the child and the benefit of therapy for the woman.
Dexamfetamine can cause dizziness, drowsiness and visual disturbances including difficulties with accommodation, diplopia and blurred vision. It may have a moderate influence on the ability to drive and use machines. Patients should be warned of these possible effects and advised that if affected, they should avoid potentially hazardous activities such as driving or operating machinery.
Dexamfetamine may affect ability to drive or operate machinery.
This medicine can impair cognitive function and can affect a patient’s ability to drive safely. This class of medicine is in the list of drugs included in regulations under 5a of the Road Traffic Act 1988. When prescribing this medicine, patients should be told:
Information on the frequency of these effects was obtained from published clinical studies and meta-analyses as well as the MHRA safety information.
Side-effect assessment is based on the following categories: very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1,000 to <1/100), rare (≥1/10,000 to <1/1,000), very rare (<1/10,000), not known (cannot be estimated from the available data).
Very rare: Anaemia, leukopenia, thrombocytopenia, thrombocytopenic purpura
Common: Arrhythmia, palpitations, tachycardia
Rare: Angina pectoris
Very rare: Cardiac arrest
Not known: Cardiomyopathy, myocardial infarction
Very rare: Tourette’s syndrome
Rare: Difficulties in visual accommodation, blurred vision, mydriasis
Common: Abdominal pain and cramps, nausea, vomiting, dry mouth
These effects usually occur at the beginning of treatment and may be alleviated by concomitant food intake.
Not known: Ischaemic colitis, diarrhoea
Not known: Chest pain, hyperpyrexia, fatigue, sudden death (see section 4.4)
Very rare: Abnormal liver function ranging from hepatic enzyme elevations to hepatic coma
Not known: hypersensitivity including angioedema and anaphylaxis
Common: Changes in blood pressure and heart rate (usually increases)
Very common: Decreased appetite, reduced weight gain and weight loss during prolonged use in children
Not known: Acidosis
Common: Arthralgia
Rare: growth retardation during prolonged use in children
Very rare: Muscle cramps
Not known: Rhabdomyolysis
Common: Vertigo, dyskinesia, headache, hyperactivity
Rare: Fatigue
Very rare: Convulsions, choreoathetoid movements, intracranial haemorrhage
Not known: Ataxia, dizziness, dysgeusia, concentration difficulties, hyperreflexia, stroke, tremor
Very rarely, cases of neuroleptic malignant syndrome (NMS) were observed. However, these reports were poorly documented and in most cases, patients were also receiving other medicinal products. Thus, the role of dexamfetamine in the development of NMS is unclear.
Very common: Insomnia, nervousness
Common: Abnormal behaviour, aggression, excitation, anorexia, anxiety, depression, irritability
Very rare: Hallucinations, psychosis / psychotic reactions, suicidal behaviour (including completed suicide), tics, worsening of pre-existing tics
Not known: Confusion, dependence, dysphoria, emotional lability, euphoria, impaired cognitive test performance, altered libido, night terrors, obsessive-compulsive behaviour, panic states, paranoia, restlessness
Not known: Renal damage
Not known: Impotence
Rare: Rash, urticaria
Very rare: Erythema multiforme, exfoliative dermatitis, fixed drug eruption
Not known: Sweating, alopecia
Very rare: Cerebral vasculitis and/or occlusion
Not known: Cardiovascular collapse, Raynaud’s phenomenon
A toxic hypermetabolic state, characterised by transient hyperactivity, hyperpyrexia, acidosis, and death due to cardiovascular collapse have been reported.
Cessation of, or reduction in amfetamine use that has been heavy and prolonged can result in withdrawal symptoms. Symptoms include dysphoric mood, fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite, psychomotor retardation or agitation, anhedonia, and drug craving.
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 or search for MHRA Yellow Card in the Google Play or Apple App Store.
Not applicable.
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