ARELIX Tablet Ref.[8907] Active ingredients: Piretanide

• hypotension
• patients with manifest or latent diabetes mellitus (regular blood sugar checks)
• patients with gout (regular check of serum levels of uric acid)
• patients with obstructed urinary flow (e.g. prostatic hypertrophy, hydronephrosis, ureteric stenosis)
• patients with cirrhosis of the liver accompanied by renal impairment
• patients with hypoproteinaemia, e.g. in nephrotic syndrome
• advanced cerebral and/or coronary sclerosis.

Piretanide should only be given to patients with impaired micturition (e.g. patients with prostatic hyperplasia) if free urinary flow is ensured because a sudden flood of urine can lead to urinary retention with over-distension of the bladder.

During prolonged treatment, serum levels of creatinine, urea and uric acid as well as glucose and electrolyte concentrations, particularly potassium, sodium, calcium, chloride and bicarbonate, should be checked regularly.

In the event of potassium loss (e.g. as a result of vomiting, diarrhoea, laxative abuse) or potassium deficiency resulting from concomitant diseases (e.g. cirrhosis of the liver) or concurrent medication (e.g. laxatives), a potassium-rich diet or potassium replacement medication is indicated. Generally speaking, a potassium-rich diet (lean meat, potatoes, bananas, tomatoes, spinach, cauliflower, dried fruit) with moderate salt restriction is recommended during treatment.

The weight loss caused by increased urinary excretion should not exceed 1 kg/day, irrespective of the extent of urinary excretion.

In nephrotic syndrome, the dose should be carefully selected because of the risk of increased side effects.

A dose adjustment is not usually necessary for elderly patients, but it is important to watch for possible impairment of renal function.

The use of Arelix can produce positive results in doping tests. In addition, the use of Arelix as a doping agent can endanger health.

Patients with the rare hereditary condition of fructose intolerance, glucose-galactose malabsorption or sucroseisomaltase deficiency should not take Arelix 6 mg prolonged-release capsules because they contain sucrose.

Based on experience with diuretics, the following interactions should be taken into consideration:

The nephrotoxic effects of certain antibiotics (e.g. aminoglycosides, cephalosporins, polymyxins) and the ototoxic effects of aminoglycosides (e.g. kanamycin, gentamicin, tobramycin) may be enhanced if piretanide is given concurrently. Resulting hearing impairment may be irreversible. Concurrent administration of the aforementioned medicinal products should therefore be avoided.

If cisplatin and piretanide are given simultaneously, there is a possibility of hearing damage. Forced diuresis with lowdose piretanide following cisplatin treatment should only be carried out while there is a positive fluid balance; otherwise, the nephrotoxicity of cisplatin may be enhanced.

If digitalis is administered concurrently, it is important to remember that potassium and magnesium deficiency increases the sensitivity of the myocardium to digitalis, which can result in cardiac arrhythmias.

If administration of piretanide is accompanied by the use of glucocorticosteroids, laxatives or carbenoxolone or frequent consumption of liquorice, it is important to bear in mind that these substances can lower the serum potassium level.

The hypotensive effect of other medicines may be potentiated. Particularly in patients who develop dehydration or salt deficiency on piretanide, concurrent administration of an ACE inhibitor may cause a blood pressure decrease (possibly even shock) and/or renal impairment (possibly even acute renal failure).

It may be necessary to increase the dose of concurrent antidiabetic drugs for patients in a diabetic metabolic condition.

There have been reports that diuretics may cause latent diabetes to become manifest or may necessitate adjustment of the dosage of concurrently administered hypoglycaemic agents.

The effect of salicylates and curare-type muscle relaxants may be increased and the effect of pressor amines (e.g. adrenaline, noradrenaline) may be reduced. The excretion of lithium via the kidneys may be reduced and hence its cardiotoxicity and neurotoxicity enhanced.

Non-steroidal anti-inflammatory drugs (e.g. indomethacin, aspirin) may weaken the efficacy of piretanide and lead to renal failure in patients with pre-existing hypovolaemia.

Probenecid may weaken the effect of piretanide.

In common with all thiazide and loop diuretics, Arelix can cause hypokalaemia. In patients with severe liver disease, Arelix may precipitate hepatic coma; the use of potassium-sparing diuretics may be preferable in the first instance in these patients.

Caution should be observed in patients liable to electrolyte imbalance; the levels of serum potassium should be monitored where cardiac glycosides or corticosteroids are to be administered and in patients with liver disease.

Arelix must not be used during the first trimester of pregnancy. There is insufficient experience to assess the safety of its use in the later phases of pregnancy.

Arelix must not be administered to breast-feeding women because the active substance piretanide is excreted in breast milk. If necessary, weaning should take place.

Treatment with this medicinal product requires regular medical checks. In individual cases reduced mental alertness may impair the ability to drive or operate dangerous machinery. This is most likely at the beginning of treatment, when there is a dose increase or a change of drug and in interaction with alcohol.

The adverse reactions for piretanide are listed below. The frequencies for these reactions are unknown.

Blood and lymphatic system disorders: thrombocytopenia, leucopenia, haemoconcentration

Metabolism and nutrition disorders: dehydration, hypovolemia, hypokalaemia, hyponatraemia, hypocalcaemia, hypomagnesaemia, decrease of glucose tolerance, latent diabetes mellitus may become manifest, deterioration of pre-existing metabolic alkalosis, increase in cholesterol and triglycerides serum levels, increase in blood creatinine and urea levels, increase in uric acid levels and attacks of gout

Vascular disorders: hypotension including orthostatic hypotension, tendency for thrombosis, vasculitis

Gastrointestinal disorders: nausea, vomiting, diarrhea, dyspepsia

Hepatobiliary disorders: cholangitis, intrahepatic cholestasis, increase in liver transaminases

Skin and subcutaneous tissue disorders: itching, urticaria, maculopapular exanthema and enanthema, erythema multiforme, photosensitivity

Renal and urinary disorders: symptoms of obstruction of urine flow may become manifest or exacerbated in patients with impaired micturation, e.g. in prostatic hypertrophy

Reproductive system and breast disorders: erectile impotence may occur as a result of blood pressure decrease

General disorders: and administration site conditions fever

Ear and labyrinth disorders: hearing disorders, such as tinnitus and deafness (sometimes irreversible)

Reporting of suspected adverse reactions

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 HPRA Pharmacovigilance, Earlsfort Terrace, IRL – Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: medsafety@hpra.ie.

Not applicable.