SURMONTIL Film-coated tablet Ref.[49836] Active ingredients:

The drug should only be used with great caution in the elderly or the debilitated.

The drug should only be used with great caution in patients with a history of epilepsy or recent convulsions, urinary retention, glaucoma, hyperthyroidism, or cardiovascular disorders, particularly in patients with recent myocardial infarction or coronary insufficiency, blood dyscrasias, alcoholism, pre-existing brain damage, or in conjunction with electroconvulsive therapy.

Patients with severe depression should be kept under close surveillance, particularly during the early stages of treatment. Patients receiving anti-depressant therapy should be kept under regular surveillance and particular attention to effects on cerebral function, haemopoietic function, myocardial conduction disorders.

Trimipramine is associated with a risk of cardiovascular adverse events in all age groups.

Antiarrhythmic agents which prolong the QT interval may increase the likelihood of ventricular arrhythmias given concomitantly with tricyclic antidepressants.

Trimipramine can cause hepatic adverse events (see Section 4.8) and is mainly metabolised by the liver. It should only be used with great caution in patients with hepatic insufficiency. It may be advisable to monitor liver function in patients on long term treatment with surmontil because of the risk of overdosage (see section 5.2).

Rare cases of withdrawal syndrome have been observed on cessation of treatment (headache, malaise, nausea, anxiety, sleep disturbances). Therefore, dosage should be reduced gradually and the patient closely monitored during this period.

Insomnia or nervousness at the start of treatment may require reduced doses or transient symptomatic treatment.

In cases of sudden manic episodes, trimipramine treatment must be discontinued and generally, a sedative neuroleptic will be administered.

For patients with epilepsy or a history of epilepsy, increased clinical EEG monitoring is recommended due to the possibility of a lowering of the convulsive threshold. The onset of seizures required discontinuation of the treatment.

Trimipramine must be used with caution:

• In elderly patients more susceptible to postural hypotension and sedation, chronic constipation (risk of paralytic ileus) and possible prostatic hypertrophy;
• In patients presenting certain cardiovascular disorders since this class of compound may increase the risk of tachycardia, hypotension and quinidine-related effects;
• In patients with renal insufficiency because of the risk of overdosage (see section 5.2).

Trimipramine should not be used in the treatment of children and adolescents under the age of 18 years. Studies in depression in this age group did not show beneficial effect for tricyclic antidepressants. Studies with other classes of antidepressants (selective serotonin reuptake inhibitors) have shown a risk of suicidality, self harm and hostility related to these compounds. This risk cannot be excluded with Trimipramine.

Furthermore, long term safety data in children and adolescents concerning growth maturation and cognitive and behavioural development are not available (see also section 4.8 Undesirable effects and section 4.9 Overdose).

Suicidal thoughts/behaviour: Depression is associated with an increased risk of suicidal thoughts, self harm and suicide (suicide-related events). This risk persists until significant remission occurs. As improvement may not occur during the first few weeks or more of treatment, patients should be closely monitored until such improvement occurs. It is general clinical experience that the risk of suicide may increase in the early stages of recovery.

Patients with a history of suicide-related events, or those exhibiting a significant degree of suicidal ideation prior to commencement of treatment are known to be at greater risk of suicidal thoughts or suicide attempts, and should receive careful monitoring during treatment. A meta-analysis of placebo-controlled clinical trials of antidepressant drugs in adult patients with psychiatric disorders showed an increased risk of suicidal behaviour with antidepressants compared to placebo in patients less than 25 years old.

Close supervision of patients and in particular those at high risk should accompany drug therapy especially in early treatment and following dose changes. Patients (and caregivers of patients) should be alerted about the need to monitor for any clinical worsening, suicidal behaviour or thoughts and unusual changes in behaviour and to seek medical advice immediately if these symptoms occur.

Anaesthetics given during tri/tetracyclic antidepressant therapy may increase the risk of arrhythmias and hypotension. If surgery is necessary, the anaesthetist should be informed that a patient is being so treated.

Surmontil tablets contain lactose monohydrate. Therefore patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption, should not take this medicine.

Hyperglycemia/Diabetes: Epidemiologic studies have identified an increased risk of diabetes mellitus in depressed patients receiving tricyclic antidepressants. Therefore, patients with an established diagnosis of diabetes mellitus or with risk factors for diabetes who are started on trimipramine, should get appropriate glycaemic monitoring (see section 4.8).

Serotonin syndrome: Serotonin syndrome may occur when tricyclic antidepressants are used concomitantly with other serotonergic active substances (see section 4.5). Serotonin Syndrome which is caused by an excess inserotonin, may be fatal and includes the following symptoms:

• Neuromuscular excitation (clonus, hyperreflexia, myoclonus, rigidity),
• Autonomic changes (hyperthermia, tachycardia, changes in blood pressure, diaphoresis, tremor, flushing, dilated pupils, diarrhea),
• Changed mental state (anxiety, agitation, confusion, coma).

Close clinical monitoring is required when serotonergic active substances are combined with trimipramine. Treatment with trimipramine should be discontinued if serotonin syndrome occurs.

QT interval prolongation: Like other tricyclic antidepressants, trimipramine may dose-dependently prolong QT interval (See section 4.8). Caution should be taken in patients with known risk factors for prolongation of QT interval such as:

• congenital long QT syndrome, bradycardia
• concomitant use of drugs that are known to prolong the QT interval, induce bradycardia or hypokalemia (See section Interactions)
• uncorrected electrolyte imbalance (e.g. hypokalemia, hypomagnesemia).

Non-selective monoamine oxidase (MAOIs) should not be used in combination with any imipramines due to the major risk (though not well documented) of hypotensive and hypertensive effects. Monoamine oxidase inhibitor therapy should be discontinued for at least 2 weeks before introduction of treatment with this drug. Administration in such patients should be conducted with great caution, commenced with low dosage and with slow increments.

Contraindicated combinations:

• Sultopride: increased risk of ventricular arrhythmias, particularly torsades de pointes as a result of added electrophysiologicial effects.
• Selegiline: increased risk of serotonin syndrome.

Inadvisable combinations:

• Alcohol: increased sedative effect of imipramines. Possible hazard when driving or operating machinery due to impaired alertness. Concomitant use of alcoholic beverages and alcohol-containing medicines should be avoided.
• Medicinal products that lower blood pressure, including antihypertensives; Increased risk of hypotension, particularly orthostatic hypotension.
• Clonidine and guanfacine (described with desipramine and imipramine): inhibition of the antihypertensive effect of clonidine (antagonism of the effect of adrenergic receptors).
• Alpha and beta sympathomimetics (epinephrine, norepinephrine, dopamine for systemic action by parenteral route): paroxysmal hypertension with possible ventricular arrhythmias (inhibition of epinephrine or of norepinephrine entry into the sympathetic fibre.
• Sulpiride: risk of QT prolongation.
• Haloperidol, Pimozide, Sertindole, Ziprasidone: increased risk of side effects on the heart.

Association requiring precautions for use:

• Antiepileptics: risk of generalised convulsive episodes (lowering of the convulsive threshold by the antidepressant). Clinical supervision and if necessary, adjustment of dosages.
• Valproic acid, valpromide: clinical supervision and if necessary, adjustment of dosage.
• Carbamazepine: risk of generalised convulsive episodes (lowering of the convulsive threshold by the antidepressant) and decreased antidepressant plasma concentrations (increased hepatic metabolism of the antidepressant by the antiepileptic drug). Clinical supervision and if necessary, adjustment of dosages.
• Specific serotoninergic antidepressants: citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline: increased plasma concentrations for both antidepressants accompanied by the risk of convulsions and enhances side effects. Concomitant administration requires increased clinical supervision and if necessary adjustment of dosage. When switching from fluoxetine treatment to imipramine antidepressant, the initial dosage should be determined with care and gradually increased due to the long half life of fluoxetine and its active metabolite.
• Alpha and beta sympathomimetics (epinephrine for local hemostatic action by subcutaneous and gingival injection): paroxysmal hypertension with possible arrhythmias (inhibition of epinephrine or of norepinephrine entry into the sympathetic fibre. Limit the dose, for example less than 0.1mg of epinephrine in 10 minutes or 0.3mg in an hour for adults.
• Co-administration with other serotonergic active substances (such as SSRIs, SNRIs, MAOIs, lithium, triptans, tramadol, linezolid, L-tryptophan, and St. John’s Wort – Hypericum perforatum – preparations) may lead to serotonin syndrome. Close clinical monitoring is required when these substances are co-administered with trimipramine.
• Trimipramine should be used with caution in patients receiving drugs known to prolong QT interval (e.g. Class IA and III antiarrhythmics, macrolides, fluoroquinolones, some antifungals, some antipsychotics), induce hypokalemia (e.g. hypokalemic diuretics, stimulant laxatives, glucocorticoids, tetracosactides) or bradycardia (e.g. beta-blockers, diltiazem, verapamil, clonidine, digitalics)

Other combinations:

• Atropine and other atropinic substances (sedative H antihistamines, antiparkinsonian drugs, anticholinergics atropinic antispasmodics, disopyramide, phenothiazinic neuroleptics); build up of atropinic side effects such as urinary retention, constipation dry mouth, etc.
• Other central nervous system (CNS) depressants: morphine derivatives (analgesics, antitussives and replacement therapies); barbiturates, benzodiazepines, anxiolytics other than benzodiazephines; carbamates, captodiame etifoxine; hypnotics; neuroleptics; sedative H antihistamines; central antihypertensives; baclofen; thalidomide, enhances CNS depression. Possible hazard when driving or operating machinery due to impaired alertness.
• Baclofen: risk of increased muscular hypotonia.
• Guanethidine (ocular route) describes with amitriptyline, desipramine, imipramine and maprotiline: reduced antihypertensive effect of guanethidine (inhibition of entry into the sympathetic fibre, site of action).
• Zopiclone; There is limited evidence that zopiclone may reduce the absorption or increase the elimination rate of trimipramine. These effects could decrease the antidepressant activity of trimipramine or related tricyclic antidepressant drugs, although the clinical evidence remains unclear.

The maintenance of good maternal mental balance throughout pregnancy is desirable. If a medicinal treatment is required to ensure this balance, it should be started or continued an an effective dose throughout the pregnancy and, if possible, as monotherapy.

In the neonates of mothers treated with an imipramine-like antidepressant at the end of pregnancy, symptoms of intoxication (especially atropine-like) and/or withdrawal have sometimes been described.

It is preferable to avoid using trimipramine during pregnancy at any stage. However, treatment should not be discontinued abruptly to avoid the risk of withdrawal for the mother. If the initiation or maintenance of treatment with trimipramine during pregnancy is unavoidable, the effects described above should be considered when monitoring the neonate.

Trimipramine is contraindicated during lactation. The drug has been shown to cross the placenta and is excreted in breast milk.

This drug may cause drowsiness, blurry vision or effect concentration. Patients receiving this medication should not drive or operate machinery unless it has been shown not to interfere with physical or mental capacity.

Side effects include mainly drowsiness or sedation (antihistamine effect) more pronounced at the start of treatment, anti-cholinergic effects, hypotension; particularly orthostatic hypotension, central nervous system irritability, gastrointestinal upset, including constipation, dryness of the mouth, accommodation difficulties, dysuria, micturition disorders and in some urinary retention, perspiration, erectile dysfunction.

Other infrequently reported side effects include vertigo, unsteadiness when standing, tachycardia, paraesthesia, tremors seizures in predisposed patients and transient confusional states. Side effects related to the depression itself include, removal of psychomotor inhibition with suicidal risk; mood swings with episodes of mania and renewed delusions in psychotic patients.

Hypersensitivity reactions such as skin rash, allergic skin reactions, dermatitis, hyperhidrosis, flushing, facial oedema, angioedema and less commonly anaphylactic reactions have been reported.

Hyperglycemia. Epidemiologic studies have identified an increased risk of diabetes mellitus in depressed patients receiving tricyclic antidepressants (see section 4.5).

QT interval prolongation, torsade de pointes (see section 4.5).

Blood disorders such as neutropenia, leucocytosis, leucopenia, thrombocytopenia, eosinophilia, hypereosinophilia and agranulocytosis have been observed.

Effects have been seen on liver function tests, raised gamma GT, increased transaminases, bilirubinemia and increased alkaline phosphatases, with more infrequent reports of jaundice, cytolytic hepatitis, choleostatic hepatitis and hepatitic necrosis.

Cardiac toxicity has been observed with reports of chest pain, cardiac failure, atrial fibrillation, conduction disorders and other arrhythmias.

Other neurological adverse effects include headache, peripheral neuropathy, tremor ataxia, convulsions, other extrapyramidal symptoms including speech difficulties and tinnitus, confusion or delirium may also occur.

Endocrine effects include gynaecomastia, breast hypertrophy and galactorrhoea with one report of hypothyroidism. Alterations in blood have also been observed and rarely inappropriate ADH secretion syndrome.

Epidemiological studies, mainly conducted in patients 50 years of age and older, show an increased risk of bone fractures in patients receiving SSRI’s or TCA’s. The mechanism leading to this risk is unknown.

Other side effects reported include pruritus, alopecia, syncope, weight gain, constipation and Stevens-Johnson syndrome.

Withdrawal symptoms including anxiety, restlessness, diarrhoea and hot and cold flushes have been reported on discontinuation of treatment.

Cases of suicidal ideation and suicidal behaviours have been reported during Surmontil therapy or early after treatment discontinuation (see section 4.4).

Some of these undesirable effects can be prevented or counteracted using adjuvant or corrective treatment or by reducing dosage.

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; Email: medsafety@hpra.ie.

Not applicable.