Source: Medicines & Healthcare Products Regulatory Agency (GB) Revision Year: 2016 Publisher: Actavis UK Limited (Trading styles: Actavis), Whiddon Valley, BARNSTAPLE, N Devon EX32 8NS
Buspirone is contraindicated in the following groups of patients.
The administration of buspirone to a patient taking a monoamine oxidase inhibitor (MAOI) may pose a hazard. There have been reports of the occurrence of elevated blood pressure when buspirone has been added to a regimen including a MAOI. Therefore, it is recommended that buspirone not be used concomitantly with a MAOI.
Buspirone should be used with care in the following situations.
Buspirone should not be used alone to treat depression, and may potentially mask the clinical signs of depression.
The long-term safety and effectiveness of buspirone have not been determined in individuals below 18 years of age. Buspirone is not recommended in children and adolescents (see section 4.2).
Buspirone is not a controlled substance.
Buspirone has shown no potential for drug abuse and dependence based on human and animal studies.
Because buspirone does not exhibit cross-tolerance with benzodiazepines and other common sedative/hypnotic drugs, it will not block the withdrawal syndrome often seen with cessation of therapy with these drugs. Therefore, before starting therapy with buspirone, it is advisable to withdraw these drugs gradually, especially in patients who have been using a CNS-depressant drug chronically.
Because its mechanism of action is not fully elucidated, long-term toxicity in the CNS or other organ systems cannot be predicted.
The concomitant use of buspirone with other CNS-active drugs should be approached with caution.
Co-administration of MAO inhibitors may cause increases in blood pressure. Co-administration of MAO inhibitors and buspirone is therefore not recommended (see section 4.4).
Concomitant administration of buspirone (10 mg as single dose) and erythromycin (1.5 g once daily for four days) in healthy volunteers increased the plasma concentrations of buspirone (Cmax increased 5-fold and AUC 6-fold). If buspirone and erythromycin are to be used in combination, a low dose of buspirone (e.g. 2.5 mg twice daily) is recommended. Subsequent dose adjustments of either drug should be based on clinical response.
Concomitant administration of buspirone (10 mg as single dose) and itraconazole (200 mg once daily for four days) in healthy volunteers increased the plasma concentrations of buspirone (Cmax increased 13-fold and AUC 19-fold). If buspirone and itraconazole are to be used in combination, a low dose of buspirone (e.g., 2.5 mg once daily) is recommended. Subsequent dose adjustments of either drug should be based on clinical response.
Concomitant administration of buspirone (10 mg as single dose) and diltiazem (60 mg three times daily) in healthy volunteers increased the plasma concentrations of buspirone (Cmax increased 5.3-fold and AUC 4-fold). Enhanced effects and increased toxicity of buspirone may be possible when buspirone is administered with diltiazem. Subsequent dose adjustments of either drug should be based on clinical response.
Concomitant administration of buspirone (10 mg as single dose) and verapamil (80 mg three times daily) in healthy volunteers increased the plasma concentrations of buspirone (Cmax and AUC increased 3.4-fold). Enhanced effects and increased toxicity of buspirone may be possible when buspirone is administered with verapamil. Subsequent dose adjustments of either drug should be based on clinical response.
Rifampicin induces the metabolism of buspirone via CYP3A4. Therefore, concomitant administration of buspirone (30 mg as single dose) and rifampicin (600 mg once daily for 5 days) in healthy volunteers decreased the plasma concentrations (Cmax decreased 84% and AUC decreased 90%) and the pharmacodynamic effect of buspirone.
Antidepressants – the occurrence of elevated blood pressure in patients receiving buspirone and monoamine oxidase inhibitors (phenelzine and tranylcypromine) has been reported. Buspirone should not be used concomitantly with a MAOI. In healthy volunteers no interaction with the tricyclic antidepressant amitriptyline was seen.
Baclofen, lofexidine, nabilone, antihistamines may enhance any sedative effect.
The combination of buspirone and selective serotonin reuptake inhibitors (SSRI) was tested in a number of clinical trials on more than 300,000 patients. Although no severe toxicities were observed, there were rare cases of seizures in patients that took SSRI and buspirone concomitantly.
Separate cases of seizures in patients administered combination therapy with buspirone and SSRIs have been reported from regular clinical use. Buspirone should be used with caution in combination with serotonergic drugs (including MAOIs, L-tryptophan, triptans, tramadol, linezolid, SSRIs, lithium and St. John’s Wort) as there are isolated reports of serotonin syndrome occurring in patients on concomitant SSRI therapy. If this condition is suspected, treatment with buspirone should be immediately discontinued and supportive symptomatic treatment should be initiated.
In vitro buspirone may displace less firmly protein-bound drugs like digoxin. The clinical significance of this property is unknown.
The coadministration of buspirone (2.5 or 5 mg twice daily) and nefazodone (250 mg twice daily) to healthy volunteers resulted in marked increases in plasma buspirone concentrations (increases up to 20-fold in Cmax and up to 50-fold in AUC) and statistically significant decreases (about 50%) in plasma concentrations of buspirone metabolite, 1-pyrimidinylpiperazine. With 5-mg twice daily doses of buspirone, slight increases in AUC were observed for nefazodone (23%) and its metabolites hydroxynefazodone (HO-NEF) (17%) and mCPP (9%). Slight increases in Cmax were observed for nefazodone (8%) and its metabolite HO-NEF (11%).
The side effect profile for subjects receiving buspirone 2.5 mg twice daily and nefazodone 250 mg twice daily was similar to that for subjects receiving either drug alone. Subjects receiving buspirone 5 mg twice daily and nefazodone 250 mg twice daily experienced side effects such as lightheadedness, asthenia, dizziness, and somnolence. It is recommended that the dose of buspirone be lowered when administered with nefazodone. Subsequent dose adjustments of either drug should be based on clinical response.
Concomitant administration of buspirone 10 mg and grapefruit juice (double strength 200 ml for 2 days) in healthy volunteers increased the plasma concentrations of buspirone (Cmax increased 4.3-fold and AUC 9.2-fold).
When administered with a potent inhibitor of CYP3A4, a low dose of buspirone, used cautiously, is recommended. When used in combination with a potent inducer of CYP3A4, e.g. phenobarbital, phenytoin, carbamazepine, St. John’s wort, an adjustment of the dosage of buspirone may be necessary to maintain busprione’s anxiolytic effect.
In short-term treatment with fluvoxamine and buspirone doubled buspirone plasma concentrations are observed compared to mono-therapy with buspirone.
Concomitant administration of trazodone showed a 3-6 fold increase of ALT in some patients.
The concomitant use of buspirone and cimetidine has shown a slight increase in the 1-(2-pyrimidinyl)-piperazine metabolite of Buspirone. Because of the high protein binding of Buspirone (around 95%) caution is advised when drugs with a high protein binding are given concomitantly.
Baclofen, lofexidine, nabilone, antihistamines may enhance any sedative effect.
In vitro studies have shown that buspirone does not displace warfarin, digoxin, phenytoin, or propranolol from plasma proteins.
After addition of buspirone to the diazepam dose regimen, no statistically significant differences in the steady-state pharmacokinetic parameters (Cmax, AUC, and Cmin) were observed for diazepam, but increases of about 15% were seen for nordiazepam, and minor adverse clinical effects (dizziness, headache, and nausea) were observed.
Concomitant administration of haloperidol and buspirone can increase haloperidol serum levels.
In humans, approximately 95% of buspirone is plasma protein bound. In vitro, buspirone does not displace tightly bound drugs (ie warfarin) from serum proteins. However, in vitro, buspirone may displace less firmly protein-bound drugs like digoxin. The clinical significance of this property is unknown.
There are reports on increases in the prothrombin time after the addition of buspirone to a treatment regimen containing warfarin.
There are no or limited amount of data from the use of buspirone in pregnant women. Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity (see section 5.3).
As a precautionary measure, it is preferable to avoid the use of buspirone during pregnancy.
The effect of buspirone on labor and delivery is unknown.
It is unknown whether buspirone or its metabolite/metabolites are excreted in human milk.
A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from buspirone therapy taking into account the benefit of breast feeding for the child and the benefit of therapy for the woman.
Buspirone has moderate influence on the ability to drive and use machines. Attention is drawn to the risks associated with drowsiness or dizziness induced by this drug (see section 4.8).
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:
Side effects of buspirone, if they occur, are generally observed at the beginning of drug therapy and usually subside with use of the medication and/or decreased dosage.
When patients receiving buspirone were compared with patients receiving placebo, dizziness, headache, nervousness, lightheaded-ness, nausea, excitement, and sweating/clamminess were the only side effects occurring with significantly greater frequency (p<0.10) in the buspirone group than in the placebo group.
The list of undesirable effects shown below is presented by system organ class, MedDRA preferred term, and frequency using the following frequency categories: very common (≥1/10), common (≥1/100, <1/10), and very rare (<1/10000).
Common: nervousness, insomnia, disturbance in attention, depression, confusional state, sleep disorder, anger
Very rare: psychotic disorder, hallucination, depersonalization, affect lability
Very common: dizziness*, headache, somnolence
Common: paraesthesia, vision blurred, coordination abnormal, tremor, tinnitus
Very rare: serotonin syndrome, convulsion, tunnel vision, extrapyramidal disorder, cogwheel rigidity, dyskinesia, dystonia, syncope, amnesia, ataxias, Parkinsonism, akathisia, restless leg syndrome, restlessness
Common: tachycardia, chest pain
Common: nasal congestion, pharyngolaryngeal pain
Common: nausea, abdominal pain, dry mouth, diarrhoea, constipation, vomiting
Common: cold sweat, rash
Rare: angioneurotic oedema, ecchymosis, urticaria
Common: musculoskeletal pain
Very rare: urinary retention
Very rare: galactorrhoea
Common: fatigue
* Dizziness includes lightheadedness.
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; website: www.mhra.gov.uk/yellowcard.
Not applicable.
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