Pharmacological action

Pharmacological action An antidepressant, an inhibitor of reuptake of serotonin and norepinephrine and weakly inhibits dopamine uptake, has no significant affinity for histamine, dopamine, choline - and adrenoreceptors. The mechanism of action of DULOXETINE is in the treatment of depression is suppressing the reuptake of serotonin and norepinephrine, as a result of increased serotonergic and noradrenergic neurotransmission in the CNS. DULOXETINE has a Central mechanism for suppressing pain syndrome, which is primarily manifested by increased pain threshold in pain of neuropathic etiology. Pharmacokinetics Suction Tablets (lat. Tabulettae) solid dosage form obtained by pressing powders and granules containing one or more medicinal substances with or without excipients, or obtained by forming a special mass. Among the tablets are distinguished: uncoated, effervescent, coated, gastro-resistant, modified-release, for use in the oral cavity. Long medicines produced and adopted mainly in the form of powders or drops, while in 1880 William apjohn not learned how to do drugs in pill form. After four years, he created a machine for tabletting medication, and in 1886 founded the Upjohn Pill and Granule Company, which existed for over a century. Tablet form in comparison with granules, powders and drops, allows to simplify dosing, to improve the accuracy of dosing. Pharmacokinetics in special clinical situations When conducting studies found some differences between pharmacokinetic processes in both men and women (mean clearance of DULOXETINE lower in women), but the need for dose adjustment based on gender is not. When conducting studies found some differences between pharmacokinetic processes between patients of middle and old age (AUC and T1/2 was longer in elderly), but the need for dose adjustment based only on the age of the patients no. In patients with end-stage chronic renal failure, on hemodialysis, Cmax and AUC of DULOXETINE was increased by 2 times. In this regard, consideration should be given to reducing the dose of the drug in patients with acute violations of the kidney. In patients with clinical signs of liver failure may slow metabolism and excretion of DULOXETINE. After a single dose of DULOXETINE at a dose of 20 mg in 6 patients with cirrhosis and moderate impaired liver function (class b on a scale child-Pugh) duration T1/2 of DULOXETINE was about 15% higher than in healthy individuals matched for age and gender with five-fold increase in average AUC. Despite the fact that the Cmax in patients with cirrhosis was the same as in healthy people, the T1/2 approximately 3 times more. Dosage The drug is taken orally. The capsules should be swallowed whole, without chewing or crushing. You cannot add the drug in food or mix with liquids, because this may cause damage to the enteric-coated pellets. The recommended initial dose of DULOXETINE is 60 mg 1 times/day regardless of the meal. Some patients to achieve a good result it is necessary to increase the dose to 60 mg 1 times/day to a maximum dose of 120 mg/day 2 reception. Systematic evaluation of the drug in the dose above 120 mg have not been conducted. In patients with chronic renal insufficiency in terminal stage (QC<30 ml/min) the initial dose is 30 mg 1 times/day. In patients with impaired liver function should reduce the initial dose of the drug or reduce the dosing frequency in patients with cirrhosis. The drug is recommended in patients older than 18 years. Clinical experience with the drug in patients over the age of 18 are not. Avoid abrupt discontinuation of therapy. Upon cessation of treatment duloxetina the dose should be gradually reduced over 1-2 weeks in order to reduce the risk of developing the syndrome "cancel". If after reducing the dose or upon discontinuation of treatment, occur severe symptoms of the syndrome of "lifting", it may be considered continuing the previously assigned dose. Subsequently the physician may continue decreasing the dose, but even more gradually. Overdose Known cases of overdose with the simultaneous intake of up to 3000 mg of DULOXETINE as one, and in combination with other drugs. This is one of those cases ended in death. However, spontaneous (postmarketing) reports included descriptions of fatal acute overdose usually combined with taking a few drugs in which the dose of DULOXETINE was not more than 1000 mg. The symptoms (isolated or combined overdose): somnolence, coma, clonic convulsions, serotonin syndrome, vomiting and tachycardia. In preclinical studies (in animals) the main signs of toxicity associated with overdose, refers to disorders of the Central nervous system and the digestive system and include such symptoms as tremors, clonic convulsions, ataxia, vomiting and loss of appetite. Treatment: no specific antidote is known, however, in the case of development of serotonin syndrome may correctional treatment ciprogeptadina and application of methods of normalization of body temperature. Should ensure sufficient supply of fresh air. It is recommended to monitor cardiac activity and to monitor vital signs, along with symptomatic and supportive treatment. Gastric lavage may be indicated in that case, if too little time has passed since the ingestion, or in symptomatic treatment. In order to limit suction may be applied activated carbon. DULOXETINE is characterized by a large volume of distribution, the efficiency of forced diuresis, hemoperfusion, exchange perfusion, is questionable.

Drug interactions The monoamine oxidase inhibitors (MAOIS). Due to the risk of serotonin syndrome DULOXETINE should not be used in combination with MAOIS and within at least 14 days after stopping MAOI. Based on the half-life of DULOXETINE, you should take a break, at least 5 days after administration of DULOXETINE before taking MAOI. For selective MAOIS reversible action, such as moclobemide, the risk of serotonin syndrome below. However, the combined use of MAOIS reversible action and DULOXETINE is not recommended. Inhibitors of isoenzyme CYP1A2. Due to the fact that the isoenzyme CYP1A2 is involved in DULOXETINE metabolism, concomitant use of DULOXETINE with potential inhibitors of isoenzyme CYP1A2 is likely to lead to higher concentrations of DULOXETINE. Powerful inhibitor of the isoenzyme CYP1A2 fluvoxamine (100 mg 1 times/day) reduced the average plasma clearance of DULOXETINE by about 77%. Caution should be exercised when prescribing DULOXETINE with inhibitors of isoenzyme CYP1A2 (for example, some of quinoline antibiotics) and use smaller doses of DULOXETINE. Drugs affecting the Central nervous system. Caution should be exercised when DULOXETINE with other drugs and means influencing the Central nervous system, especially with those who have similar mechanism of action, including alcohol. Concomitant use with other drugs with serotonergic effects (for example, ISSN, SSRIs, triptana and tramadol) can lead to the development of serotonin syndrome. Serotonin syndrome. In rare cases, when coupled with the use of SSRIs (e.g. paroxetine, fluoxetine) and serotonergic drugs was observed serotonin syndrome. Care must be taken when using DULOXETINE together with serotonergic antidepressants such as SSRIs, tricyclic antidepressants (clomipramine or amitriptyline), St. John's wort, venlafaxine or triptan, tramadol, findin and tryptophan. The drugs that are metabolized by the isoenzyme CYP1A2. The simultaneous use of DULOXETINE (60 mg 2 times/day) had no significant effect on the pharmacokinetics of theophylline is metabolized by the isoenzyme CYP1A2. DULOXETINE is unlikely to have clinically significant effects on the metabolism of substrates of the isoenzyme CYP1A2. Drugs that are metabolized by CYP2D6 isoenzyme. DULOXETINE is a moderate inhibitor of CYP2D6 isoenzyme. When taking DULOXETINE at a dose of 60 mg 2 times/day with a single reception dezipramina, a substrate of CYP2D6 isoenzyme, AUC dezipramina increases in 3 times. Coadministration of DULOXETINE (40 mg 2 times/day) increased the equilibrium concentration of tolterodine (2 mg, 2 times/day) by 71%, but had no effect on the pharmacokinetics of 5 - gidroksimetabolita. Thus, caution should be exercised when using DULOXETINE with drugs that are mainly metabolized by the system of the isoenzyme CYP2D6 and have a narrow therapeutic index. Inhibitors of CYP2D6 isoenzyme. Since the isoenzyme CYP2D6 is involved in DULOXETINE metabolism, concomitant use of DULOXETINE with potential inhibitors of isoenzyme CYP2D6 may result in increased concentrations of DULOXETINE. Paroxetine (20 mg 1 times/day) reduced the average clearance of DULOXETINE by about 37%. When DULOXETINE with inhibitors of CYP2D6 isoenzyme (such as SSRIs) should be used with caution. Oral contraceptives and other steroid drugs. The results of in vitro studies demonstrate that DULOXETINE does not induce the catalytic activity of the isoenzyme CYP3A. Specific studies of drug interactions in vivo was conducted. Anticoagulants and antithrombotic drugs. Due to the potential increased risk of bleeding associated with pharmacodynamic interactions, caution must be exercised when coupled with the use of DULOXETINE and anticoagulants or antithrombotic drugs. In addition, the joint use of DULOXETINE and warfarin increased the value of the MHO. Nevertheless,concomitant use of DULOXETINE and warfarin at steady-state conditions in healthy volunteers under clinical pharmacology studies revealed no clinically significant changes in the MHO indicator medium or changes in the pharmacokinetics of right - or left-handed isomer of warfarin. Antacids and H2 antagonists-histamine receptors. The combined use of DULOXETINE and aluminum - and magnesium-containing antacids, or DULOXETINE and famotidine had no significant effect on the degree of absorption of DULOXETINE when using a dose of 40 mg. Inducers of isoenzyme CYP1A2. Population pharmacokinetic analysis showed that compared to non-Smoking patients, patients who smoke, the concentration of DULOXETINE in the plasma is nearly 50% lower. Drugs that are highly bound to proteins in the blood. DULOXETINE is largely bound to plasma proteins (> 90%). Therefore, the appointment of DULOXETINE to a patient taking another drug that has a high degree of binding to plasma proteins, may lead to increased concentrations of free fractions of both drugs. Cases of seizures and tinnitus were also observed after treatment with DULOXETINE. 2 Orthostatic hypotension and syncope were observed especially at the beginning of treatment. 3 Cm. the section "Special instructions". 4 Cases of aggression and hostility was observed especially at the beginning of treatment DULOXETINE or after its completion. 5 Cases of suicidal thoughts or suicidal behavior were observed during therapy DULOXETINE or in the early period after completion of treatment. 6 the Estimated frequency of adverse reactions. Was not observed during clinical trials. 7 Also includes hemorrhagic diarrhea, bleeding from the lower GI tract, vomiting blood, hemorrhoidal bleeding, melena, rectal bleeding, peptic ulcer bleeding. Padania met more frequently in the elderly (?65 years). 9 Including pain in the upper and lower abdomen, the tension of the anterior abdominal wall, abdominal discomfort, and gastrointestinal pain. 10 Including inner trembling, restlessness, tension, agitation. 11 Including night waking, early morning awakening, difficulty falling asleep. 12 Including hypersomnia, sedation. Wicca asthenia. Wicca increase systolic BP, diastolic pressure, systolic hypertension, diastolic hypertension, essential hypertension, hypertension. Wicca anorexia. Wicca muscle rigidity. Wicca myalgia and neck pain. Wicca the hyperesthesia, hyperesthesia of the face, hyperesthesia the genital area, the paresthesia of the mouth, very rare (<0.01%) the feeling of electric shock (at the termination of therapy). 19 Including confusion. 20 Including nightmares. 21 Including lack of ejaculation. 22 No statistically significant differences with placebo. Cancel DULOXETINE (especially simultaneously) often leads to a syndrome of "lifting" that includes the following symptoms: dizziness, sensory disturbances (including paraesthesia), sleep disturbances (including insomnia and vivid dreams), weakness, somnolence, agitation or anxiety, nausea and/or vomiting, tremor, headache, irritability, diarrhea, hyperhidrosis and vertigo. Overall, when taking selective inhibitors of serotonin reuptake (SSRI) and inhibitors of reuptake of serotonin and norepinephrine (ISSN), these effects are mild or moderate severity and limited in nature. However, in some patients, these effects may be more severe and/or prolonged. For this reason, if you cancel DULOXETINE recommended a gradual reduction in dose. With a short intake of DULOXETINE (up to 12 weeks) in patients with a painful form of diabetic peripheral neuropathy was observed a slight increase in the fasting blood glucose on the background of maintaining a stable concentration of glycosylated hemoglobin as taking DULOXETINE and the placebo group. When long-term therapy with DULOXETINE (up to 52 weeks) there was some increase in the concentration of glycosylated hemoglobin, which is 0.3% exceeded the increase of the respective indicator in patients receiving other treatment. In relation to the concentration of fasting glucose and total cholesterol in the blood in patients taking DULOXETINE, there was a slight increase in these parameters compared with a slight decrease observed in the control group patients. Corrected (relative HR) value of QT interval in patients taking DULOXETINE did not differ from that in the placebo group. Clinically significant differences between the indices of QT intervals, PR, QRS, or QTcB in the group of patients taking DULOXETINE and the placebo group was not.

Because coadministration of the drug with alcohol can have an effect similar to the effect of disulfiram (hot flashes, vomiting, tachycardia), you should warn patients that during the treatment Flagellum should not consume alcoholic beverages or medications containing alcohol. The long-term administration of the preparation is preferably carried out under the control of the blood formula. Leukopenia the possibility of further treatment depends on the risk of development of infectious process. In the treatment of Trichomonas vaginitis in women and Trichomonas urethritis in men should refrain from sexual activity. Necessarily simultaneous treatment of sexual partners. Treatment does not stop during menstruation. After therapy for trichomoniasis should conduct a control sample for 3 regular cycles before and after menstruation. After the treatment of giardiasis, if symptoms persist, after 3-4 weeks to spend 3 analysis of feces at intervals of several days (some successfully treated patients with lactose intolerance, caused by infestation may persist for several weeks or months, reminding the symptoms of giardiasis). Should discontinue treatment with the appearance of ataxia, dizziness, hallucinations, worsening of the neurological status of patients. You must take into account that metronidazole can be immobilized Treponema, which leads to false-positive test Nelson. Effects on ability to drive vehicles and management mechanisms In connection with the possibility of dizziness and other side effects associated with taking the drug, it is recommended to refrain from driving and other mechanisms. When kidney functions When expressed violations kidney (KK less 10 ml/min) is recommended to reduce the daily dose in 2 times.The terms and conditions of storage List B. the Drug should be kept out of the reach of children at a temperature from 15 to 30C. shelf Life 3 years. Do not use after expiry date. Readings depression; painful form of diabetic neuropathy; generalized anxiety disorder; chronic pain syndrome of the musculoskeletal system (including those caused by fibromyalgia, chronic pain in lower back pain and in osteoarthritis of the knee joint). Contraindications hypersensitivity to the drug components; concomitant use with MAO inhibitors; uncompensated angle-closure glaucoma; children up to age 18; sucrase/isomaltase deficiency, fructose intolerance, glucose-galactosemia malabsorption; liver disease, liver failure accompanied; concurrent administration of potent inhibitors of isoenzyme CYP1A2 (fluvoxamine, ciprofloxacin, enoxacin); severe chronic renal failure (KK less 30 ml/min); uncontrolled hypertension; children up to age 18; With caution use in mania and bipolar disorder (including in history), convulsions (including in history), intraocular hypertension, or are at risk of developing an acute attack of angle-closure glaucoma, suicidal thoughts and attempts in history, increased risk of hyponatremia (elderly patients, cirrhosis, dehydration, diuretics), liver dysfunction and renal failure (QC 30-60 ml/min). Special instructions Exacerbation of manic/hypomanic state. As with the use of similar drugs that affect the Central nervous system, DULOXETINE should be used with caution in patients with manic episodes in history. Epileptic seizures. As with the use of similar drugs that affect the Central nervous system, DULOXETINE should be used with caution in patients with epileptic seizures in history. Mydriasis. There have been cases of mydriasis while taking DULOXETINE, therefore, caution should be exercised when prescribing DULOXETINE to patients with increased intraocular pressure or those at risk of developing acute angle-closure glaucoma. Increase in blood pressure. In a few cases noted the rise in blood pressure during treatment with DULOXETINE. In patients with arterial hypertension and/or other cardiovascular diseases is recommended that blood pressure measurement. The liver or kidneys. In patients with severe impaired renal function (QC<30 ml/min) or severe hepatic insufficiency, there is an increase in the concentration of DULOXETINE in the plasma. If such patients receiving DULOXETINE clinically justified, you should use a lower initial dose of the drug. Suicidal behavior. The risk of suicide exists in all patients with depression and certain other mental disorders. This risk may persist until remission. As a consequence, patients in whom the risk of suicide is highest, should pharmacotherapy be under careful medical supervision. As well as taking other medications with similar duloxetina the mechanism of the pharmacological action (SSRIs, ISSN), the reception of DULOXETINE in the treatment process, or when to end it in some cases was associated with the development of suicidal thoughts and suicidal behavior. The use of DULOXETINE in patients under 18 years of age were not studied, and this drug is not intended for use in these patients. A causal relationship between administration of DULOXETINE and the occurrence of suicidal events in patients in this age group is not established. At the same time, some analytical reviews of results of several studies with the use of antidepressants for the treatment of mental disorders indicate an increased risk of suicidal ideation and/or suicidal behavior in children, adolescents and adults younger than 25 years compared with placebo. Doctors should encourage patients at any time to report all the troubling thoughts and feelings.

Increased risk of bleeding. SSRIs and ISSN, including DULOXETINE, may increase the risk of bleeding, including gastrointestinal. Therefore, DULOXETINE should be used with caution in patients taking anticoagulants and/or medicinal products that affect platelet function (e.g. NSAIDs, acetylsalicylic acid) and patients with a tendency to bleeding disorder. Hyponatremia. Very rarely reported cases of hyponatremia (in some cases, the content of serum sodium lower than 110 mmol/l). The majority of these cases occurred in elderly patients, especially in combination with altered fluid balance in recent history or in the presence of conditions predisposing to changes in fluid balance. Hyponatremia can manifest in the form of nonspecific symptoms (such as dizziness, weakness, nausea, vomiting, confusion, drowsiness, lethargy). The signs and symptoms, manifested in more severe cases, included fainting, falling, and seizures. The monoamine oxidase inhibitors (MAOIS). In patients taking an inhibitor of serotonin reuptake in combination with an MAOI, there have been cases of serious reactions, sometimes fatal, among whom met hyperthermia, rigidity, myoclonus, peripheral disturbance with possible rapid fluctuations of indicators of vital functions and alterations in mental status, including full-blown excitement with the transition to delirium and coma. These reactions are also observed in patients shortly before the appointment of MAOIS has been cancelled inhibitor of serotonin reuptake. In some cases, the patients had symptoms characteristic of neuroleptic malignant syndrome. Effects of the combined use of DULOXETINE and MAOIS have not been assessed in either humans or animals. Therefore, given the fact that DULOXETINE is an inhibitor of the reuptake and serotonin, and norepinephrine, it is not recommended to take DULOXETINE in combination with an MAOI or within at least 14 days after stopping MAOI. Based on the half-life of DULOXETINE, you should take a break, at least 5 days after administration of DULOXETINE before taking MAOI. Increased activity of hepatic enzymes. Some patients taking DULOXETINE in clinical studies, it was observed an increase in the activity of liver enzymes. The observed deviations were, as a rule, temporary and disappear spontaneously, or after discontinuation of DULOXETINE. A serious increase in the activity of liver enzymes (10 times or more greater than ULN) and liver damage cholestatic or mixed origin were rare, and in some cases have been associated with excessive alcohol use, or previous hepatic disease. Recommended be wary of DULOXETINE in patients who consume alcohol in large quantities, as well as with existing liver disease. Effects on ability to drive vehicles and management mechanisms In patients receiving DULOXETINE may experience sedation, drowsiness and other side effects. In this regard, patients receiving DULOXETINE, caution should be exercised in the management of hazardous mechanical means, including by car. When kidney functions To use caution in renal failure (QC 30-60 ml/min). When human liver To use caution if impaired liver.