OXYNORM 10 mg/ml Solution for injection or infusion Ref.[27710] Active ingredients: Oxycodone

As with all opioids, a reduction in dosage may be advisable in hypothyroidism. Use with caution in debilitated elderly or patients with severely impaired respiratory function, sleep apnoea, tolerance, physical depedance, withdrawal, psychological dependence [addiction], abuse profile, history of substance and/or alcohol abuse, head injury, intracranial lesions or raised intracranial pressure, reduced level of consciousness of uncertain origin, alcoholism, constipation, hypotension, hypovolaemia, toxic psychoses, diseases of the biliary tract, inflammatory bowel disorders, prostatic hypertrophy, adrenocortical insufficiency, acute alcoholism, delirium tremens, pancreatitis, severely impaired renal and hepatic function or severe pulmonary disease and debilitated, elderly and infirm patients. myxedema, Addison’s disease, patients taking benzodiazepines, other CNS depressants (including alcohol) or MAO inhibitors (see below and Section 4.5). OxyNorm injection should not be used where there is a possibility of paralytic ileus occurring. Should paralytic ileus be suspected or occur during use, OxyNorm injection should be discontinued immediately.

Respiratory depression

The primary risk of opioid excess is respiratory depression.

Sleep-related breathing disorders

Opioids can cause sleep-related breathing disorders including central sleep apnoea (CSA) and sleep-related hypoxemia. Opioid use increases the risk of CSA in a dose-depended fashion. In patients who present with CSA, consider decreasing the total opioid dosage.

Opioids may also cause worsening of pre-existing sleep apnoea (see section 4.8).

CNS depressants co-administration

Concomitant use of OxyNorm injection and sedative medicines such as benzodiazepines or related drugs may result in sedation, respiratory depression, coma and death. Because of these risks, concomitant prescribing with these sedatives medicines should be reserved for patient for whom alternative treatment options are not possible. If a decision is made to prescribe oxycodone concomitantly with sedative medicines, the lowest effective dose should be used, and the duration of treatment should be as short as possible.

The patients should be followed closely for signs and symptoms of respiratory depression and sedation. In this respect, it is strongly recommended to inform patients and their caregivers to be aware of these symptoms (see section 4.5).

Opioids, such as oxycodone hydrochloride may influence the hypothalamic-pituitary-adrenal or – gonadal axes. Some changes that can be seen include an increase in serum prolactin, and decreases in plasma cortisol and testosterone. Clinical symptoms may be manifest from these hormonal changes.

MAOIs

Oxycodone must be administered with caution in patients taking MAOIs or who have received MAOIs within the previous two weeks.

Tolerance and withdrawal

The patient may develop tolerance to oxycodone with chronic use and require progressively higher doses to maintain pain control. The patient may develop physical dependence, in which case an abstinence syndrome may be seen following abrupt cessation. When a patient no longer requires therapy with oxycodone, it may be advisable to taper the dose gradually to prevent symptoms of withdrawal.

Opioids are not first-line therapy for chronic non-malignant pain, nor are they recommended as the only treatment. Opioids should be used as part of a comprehensive treatment programme involving other medications and treatment modalities. Patients with chronic non-malignant pain should be assessed and monitored for addiction and substance abuse.

For appropriate patients who suffer with chronic non-malignant pain, opioids should be used as part of a comprehensive treatment programme involving other medications and treatment modalities. A crucial part of the assessment of a patient with chronic non-malignant pain is the patient’s addiction and substance abuse history.

If opioid treatment is considered appropriate for the patient, then the main aim of treatment is not to minimize the dose of opioid but rather to achieve a dose which provides adequate pain relief with a minimum of side effects.

Psychological dependence [addiction], abuse profile and history of substance and/or alcohol

As with other opioids, infants who are born to dependent mothers may exhibit withdrawal symptoms and may have respiratory depression at birth.

Opioid Use Disorder (abuse and dependence)

Tolerance and physical and/or psychological dependence may develop upon repeated administration of opioids such as oxycodone.

Repeated use of OxyNorm injection may lead to Opioid Use Disorder (OUD). A higher dose and longer duration of opioid treatment can increase the risk of developing OUD. Abuse or intentional misuse of OxyNorm injection may result in overdose and/or death. The risk of developing OUD is increased in patients with a personal or a family history (parents or siblings) of substance use disorders (including alcohol use disorder), in current tobacco users or in patients with a personal history of other mental health disorders (e.g. major depression, anxiety and personality disorders).

Before initiating treatment with OxyNorm injection and during the treatment, treatment goals and a discontinuation plan should be agreed with the patient (see section 4.2). Before and during treatment the patient should also be informed about the risks and signs of OUD. If these signs occur, patients should be advised to contact their physician.

Patients will require monitoring for signs of drug-seeking behavior (e.g. too early requests for refills). This includes the review of concomitant opioids and psycho-active drugs (like benzodiazepines). For patients with signs and symptoms of OUD, consultation with an addiction specialist should be considered.

This medicinal product contains less than 1 mmol sodium (23 mg) per ml, that is to say essentially ‘sodium-free’.

The concomitant use of opioids with sedative medicines such as benzodiazepines or related drugs increases the risk of sedation, respiratory depression, coma and death because of additive CNS depressant effect. The dose and duration of concomitant use should be limited (see section 4.4). Drugs which depress the CNS include, but are not limited to: other opioids, gabapentinoids such as pregabalin, anxiolytics, hypnotics and sedatives (incl. benzodiazepines), antipsychotics, antidepressants, phenothiazines and alcohol. Concomitant administration of oxycodone with serotonin agents, such as a Selective Serotonin Re-uptake Inhibitor (SSRI) or a Serotonin Norepinephrine Re-uptake Inhibitor (SNRI) may cause serotonin toxicity. The symptoms of serotonin toxicity may include mental-status changes (e.g., agitation, hallucinations, coma), autonomic instability (e.g., tachycardia, labile blood pressure, hyperthermia), neuromuscular abnormalities (e.g., hyperreflexia, incoordination, rigidity), and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhoea). Oxycodone should be used with caution and the dosage may need to be reduced in patients using these medications.

Concomitant administration of oxycodone with anticholinergics or medications with anticholinergic activity (e.g tricyclic antidepressants, antihistamines, antipsychotics, muscle relaxants, anti-Parkinson drugs) may result in increased anticholinergic adverse effects.

Monoamine oxidase inhibitors are known to interact with narcotic analgesics, producing CNS excitation or depression with hypertensive or hypotensive crisis. Co-administration with monoamine oxidase inhibitors or within two weeks of discontinuation of their use is inappropriate.

Oxycodone is metabolized in part via the CYP2D6 and CYP3A4 pathways. While these pathways may be blocked by a variety of drugs, such blockade has not yet been shown to be of clinical significance with this agent.

The effect of oxycodone in human reproduction has not been adequately studied. No studies on fertility or the post-natal effects of intrauterine exposure have been carried out. However, studies in rats and rabbits with oral doses of oxycodone equivalent to 3 and 47 times an adult dose of 160 mg/day, respectively, did not reveal evidence of harm to the foetus due to oxycodone. OxyNorm injection is not recommended for use in pregnancy nor during labour. Infants born to mothers who have received opioids during pregnancy should be monitored for respiratory depression.

Oxycodone may be secreted in breast milk and may cause respiratory depression in the newborn. Oxycodone should therefore not be used in breast-feeding mothers.

Fertility

No human data on the effect of oxycodone on fertility are available. In rats, there was no effect on mating or fertility with oxycodone treatment (see section 5.3).

Oxycodone may modify patients' reactions to a varying extent depending on the dosage and individual susceptibility. Therefore patients should not drive or operate machinery, if affected.

This medicine can impair cognitive function and can affect a patient’s ability to drive safely. When prescribing this medicine, patients should be told:

• The medicine is likely to affect your ability to drive.
• Do not drive until you know how the medicine affects you.
• It is an offence to drive while you have this medicine in your body over a specified limit unless you have a defence (called the ‘statutory defence’).
• This defence applies when:
  • The medicine has been prescribed to treat a medical or dental problem; and
  • You have taken it according to the instructions given by the prescriber and in the information provided with the medicine.
• Please note that it is still an offence to drive if you are unfit because of the medicine (i.e. your ability to drive is being affected)."

Adverse drug reactions are typical of full opioid agonists. Tolerance and dependence may occur (see Tolerance and Dependence, below). Constipation may be prevented with an appropriate laxative. If nausea or vomiting are troublesome, oxycodone may be combined with an antiemetic.

The undesirable effects listed below are classified by body system according to their incidence (common or uncommon). The following frequencies are basis for assessing undesirable effects: Very Common (≥1/10), Common (≥1/100 to <1/10), Uncommon (≥1/1000 to <1/100), Rare (≥1/10000 to <1/1000), Very Rare (<1/10000), Not Known (cannot be estimated from the available data).

Common adverse drug reactions have an incidence of 21% and uncommon adverse drug experiences have an incidence of <1%.

Tolerance and Dependence

The patient may develop tolerance to the drug with chronic use and require progressively higher doses to maintain pain control. Prolonged use of OxyNorm injection may lead to physical dependence and a withdrawal syndrome may occur upon abrupt cessation of therapy. When a patient no longer requires therapy with oxycodone, it may be advisable to taper the dose gradually to prevent symptoms of withdrawal. The opioid abstinence or withdrawal syndrome is characterized by some or all of the following: restlessness, lacrimation, rhinorrhoea, yawning, perspiration, chills, myalgia, and mydriasis. Other symptoms also may develop, including: irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhea, or increased blood pressure, respiratory rate or heart rate.

The development of psychological dependence (addiction) to opioid analgesics in properly managed patients with pain has been reported to be rare. However, data are not available to establish the true incidence of psychological dependence (addiction) in chronic pain patients.

OxyNorm injection should be used with particular care in patients with a history of alcoholic and drug abuse.

Drug dependence

Repeated use of OxyNorm injection can lead to drug dependence, even at therapeutic doses. The risk of drug dependence may vary depending on a patient’s individual risk factors, dosage, and duration of opioid treatment (see section 4.4).

Paediatric population

The frequency, type and severity of adverse reactions in adolescents (12 to 18 years of age) appear similar to those in adults (see section 5.1).

Reporting of suspected adverse reactions

Reporting suspected adverse reactions is an important way to gather more information to continuously monitor the benefit/risk balance of the medicinal product. Any suspected adverse reactions should be reported to: Pharmaceutical Services, Ministry of Health, CY-1475, Nicosia, Cyprus, Tel: +357 22608607, Fax: +357 22608669, Website: www.moh.gov.cy/phs.

This medicinal product must not be mixed with other medicinal products except those mentioned in section 6.6.

Cyclizine at concentrations of 3 mg/ml or less, when mixed with OxyNorm injection, either undiluted or diluted with water for injections, shows no sign of precipitation over a period of 24 hours storage at room temperature. Precipitation has been shown to occur in mixtures with OxyNorm injection at cyclizine concentrations greater than 3 mg/ml or when diluted with 0.9% saline. However, if the dose of OxyNorm injection is reduced and the solution is sufficiently diluted with Water for Injections, concentrations greater than 3 mg/ml are possible. It is recommended that water for injections be used as a diluent when cyclizine and oxycodone hydrochloride are co-administered either intravenously or subcutaneously as an infusion.

Prochlorperazine is chemically incompatible with OxyNorm injection.

OxyNorm injection has been shown to be compatible with the following drugs:

Hyoscine butylbromide
Hyoscine hydrobromide
Dexamethasone sodium phosphate
Haloperidol
Midazolam hydrochloride
Metoclopramide hydrochloride
Levomepromazine hydrochloride