Ziralton Allergy Relief for Children 5mg/5ml Oral Solution

In adults and children 6 year and above:

- Cetirizine is indicated for the relief of nasal and ocular symptoms of seasonal and perennial allergic rhinitis.

- Cetirizine is indicated for the relief of symptoms of chronic idiopathic urticaria.

Children aged from 6 to 12 years: 5 mg twice daily (5 ml oral solution (a full spoon twice daily).

Adults and adolescents over 12 years of age: 10 mg once daily (10 ml oral solution (2 full spoons)).

The solution can be swallowed as such.

Elderly subjects: There is no data to suggest that the dose should be reduced in elderly patients, provided that the renal function is normal.

For patients with moderate to severe renal impairment: there are no data to document the efficacy/safety ratio in patients with renal impairment. Since cetirizine is mainly eliminated via renal route (see section 5.2), in cases no alternative treatment can be used, the dosing intervals must be individualised according to renal function. Refer to the following table and adjust the dose as indicated. To use this dosing table, an estimate of the patient's creatinine clearance (CLcr) in ml/min is needed. The CLcr (ml/min) may be estimated from serum creatinine (mg/dl) determination using the following formula:

Dosing adjustments for adult patients with impaired renal function

In paediatric patients suffering from renal impairment, the dose will have to be adjusted on an individual basis taking into account the renal clearance of the patient, their age and their body weight.

Patients with hepatic impairment: no dose adjustment is needed in patients with solely hepatic impairment.

Patients with hepatic and renal impairment: dose adjustment is recommended (see Patients with moderate to severe renal impairment above).

Method of administration:

For oral use only.

Cetirizine is contraindicated in patients who are hypersensitive to cetirizine, to any constituent of the product, to hydroxyzine or to any piperazine derivatives.

Cetirizine is also contraindicated in patients with severe renal impairment at less than 10 ml/min creatinine clearance.

(See also section 4.7 Effects on Ability to Drive and Use Machines).

Dosage adjustment is necessary in patients with moderate or severe renal impairment (see section 4.2 Posology and Method of Administration).

At therapeutic doses, no clinically significant interactions have been demonstrated with alcohol (for a blood alcohol level of 0.5 g/l). Nevertheless, precaution is recommended if alcohol is taken concomitantly.

Caution should be taken in patients with predisposition factors of urinary retention (e.g. spinal cord lesion, prostatic hyperplasia) as cetirizine may increase the risk of urinary retention.

Caution in epileptic patients and patients at risk of convulsions is recommended.

The use of the product is not recommended in children aged less than 6 years.

Excipients: Methyl parahydroxybenzoate, Propyl parahydroxybenzoate, Sorbitol, Propylene glycol, Sodium and Ethanol

Methyl parahydroxybenzoate and Propyl parahydroxybenzoate

This medicinal product also contains Methyl parahydroxybenzoate and Propyl parahydroxybenzoate which may cause allergic reactions (possibly delayed).

Sorbitol

Patients with rare hereditary problems of fructose intolerance should not take this medicinal product as it contains Liquid Sorbitol (E420).

Sorbitol may cause gastrointestinal discomfort and mild laxative effect.

Propylene glycol:

This medicine contains 500 mg propylene glycol per 10 ml dose which is equivalent to 50 mg/ml.

Sodium

This medicine contains less than 1 mmol sodium (23 mg) per 10 ml, that is to say essentially 'sodium-free'.

Ethanol:

This medicine contains 0.0525 mg of alcohol (ethanol) in each 10 ml which is equivalent to 0.00065625 v/v%. The amount in 10 ml of this medicine is equivalent to less than 1 ml beer or 1 ml wine. The small amount of alcohol in this medicine will not have any noticeable effects.

For patients whose symptoms persist, it is advised to consult a doctor or pharmacist.

Allergy skin tests are inhibited by antihistamines and a wash-out period (of 3 days) is required before preforming them.

Pruritus and/or urticaria may occur when cetirizine is stopped, even if those symptoms were not present before treatment initiation. In some cases, the symptoms may be intense and may require treatment to be restarted. The symptoms should resolve when the treatment is restarted.

Paediatric population

Due to the amount of some excipients in the formulation, the use of the product is not recommended in children aged less than 6 years.

Due to the pharmacokinetic, pharmacodynamic and tolerance profile of cetirizine, no interactions are expected with this antihistamine. Actually, neither pharmacodynamic nor significant pharmacokinetic interaction was reported in drug-drug interactions studies performed, notably with pseudoephedrine or theophylline (400 mg/day).

The extent of absorption of cetirizine is not reduced with food, although the rate of absorption is decreased.

In sensitive patients, the concurrent use of alcohol or other CNS depressants may cause additional reductions in alertness and impairment of performance, although cetirizine does not potentiate the effect of alcohol (0.5 g/l blood levels).

Pregnancy

For cetirizine prospectively collected data on pregnancy outcomes do not suggest potential for maternal or foetal/embryonic toxicity above background rates. Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, parturition or postnatal development. Caution should be exercised when prescribing to pregnant women.

Breast-feeding

Cetirizine passes into breast milk. A risk of side effects in breastfed infants cannot be excluded. Cetirizine is excreted in human milk at concentrations representing 25% to 90% of those measured in plasma, depending on sampling time after administration. Caution therefore should be exercised when prescribing cetirizine to lactating women.

Fertility

Limited data is available on human fertility but no safety concern has been identified.

Animal data show no safety concern for human reproduction.

Objective measurements of driving ability, sleep latency and assembly line performance have not demonstrated any clinically relevant effects at the recommended dose of 10 mg.

However, patients who experience somnolence should refrain from driving, engaging in potentially hazardous activities or operating machinery. They should not exceed the recommended dose and should take their response to the medicinal product into account.

In sensitive patients, concurrent use with alcohol or other CNS depressants may cause additional reductions in alertness and impairment of performance.

Clinical studies have shown that cetirizine at the recommended dosage has minor adverse effects on the CNS, including somnolence, fatigue, dizziness and headache. In some cases, paradoxical CNS stimulation has been reported.

Although cetirizine is a selective antagonist of peripheral H₁-receptors and is relatively free of anticholinergic activity, isolated cases of micturition difficulty, eye accommodation disorders and dry mouth have been reported. Affected patients may divide their daily dose, i.e. take as 5 mg in the morning and 5 mg in the evening.

Instances of abnormal hepatic function with elevated hepatic enzymes accompanied by elevated bilirubin have been reported. Mostly this resolves upon discontinuation of the treatment with cetirizine hydrochloride.

Clinical Trials

Double blind controlled clinical or pharmacological trials comparing cetirizine to placebo or other antihistamines at the recommended dosage (10 mg daily for cetirizine) of which quantified safety data are available, included more than 3200 subjects exposed to cetirizine.

From this pooling, the following adverse events were reported for cetirizine 10 mg in the placebo-controlled trials at rates of 1.0% or greater.

Although statistically more common than under placebo, somnolence was mild to moderate in the majority of cases. Objective tests as demonstrated by other studies have demonstrated that usual daily activities are unaffected at the recommended daily dose in healthy young volunteers.

Paediatric population

Adverse drug reactions at rates of 1% or greater in children aged from 6 months to 12 years, included in placebo-controlled clinical or pharmacoclinical trials are:

Post-marketing experience

In addition to the adverse reactions reported during clinical studies and listed above, the following undesirable effects have been reported in post-marketing experience.

Undesirable effects are described according to MedDRA System Organ Class and by estimated frequency based on post-marketing experience.

Frequencies are defined as follows: Very common (≥ 1/10); common (≥ 1/100 to <1/10); uncommon (≥ 1/1,000 to <1/100); rare (≥ 1/10,000 to <1/1,000); very rare (<1/10,000), not known (cannot be estimated from the available data)

Blood and lymphatic system disorders

Very rare: thrombocytopenia

Immune system disorders:

Rare: hypersensitivity

Very rare: anaphylactic shock

Metabolism and nutrition disorders:

Not known: increased appetite

Psychiatric disorders

Uncommon: agitation

Rare: aggression, confusion, depression, hallucination, insomnia

Very rare: tic

Not known: suicidal ideation, nightmare

Nervous system disorders

Uncommon: paraesthesia

Rare: convulsions,

Very rare: syncope, dysgeusia, tremor, dystonia, dyskinesia

Not known: amnesia, memory impairment

Eye disorders

Very rare: accommodation disorder; blurred vision; oculogyration

Ear and labyrinth disorders:

Not known: vertigo

Cardiac disorders

Rare: tachycardia

Gastrointestinal disorders

Uncommon: diarrhoea

Hepatobiliary disorders:

Rare: abnormal hepatic function (increased transaminases, alkaline, phosphatase, gamma-GT and bilirubin)

Not known: hepatitis

Skin and subcutaneous tissue disorders

Uncommon: rash, pruritus

Rare: urticaria

Very rare: angioneurotic oedema, fixed drug eruption (FDE)

Not known: acute generalized exanthematous pustulosis

Musculoskeletal and connective tissue disorders

Not known: arthralgia

Renal and urinary disorders

Very rare: dysuria, enuresis,

Not known: urinary retention

General disorders and administration site conditions

Uncommon: asthenia, malaise

Rare: oedema

Investigations

Rare: weight increase

Description of selected adverse reactions

After discontinuation of cetirizine, pruritus (intense itching) and/or urticaria have been reported.

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 the Yellow Card Scheme at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

Symptoms

Symptoms observed after an overdose of cetirizine are mainly associated with CNS effects or with effects that could suggest an anticholinergic effect.

Adverse events reported after an intake of at least 5 times the recommended daily dose are: confusion, diarrhoea, dizziness, fatigue, headache, malaise, mydriasis, pruritus, restlessness, sedation, somnolence, stupor, tachycardia, tremor and urinary retention.

Management

There is no known specific antidote to cetirizine.

Should overdose occur, symptomatic or supportive treatment is recommended. Gastric lavage should be considered following ingestion of a short occurrence. In addition active charcoal should be considered if cetirizine has been ingested within 1 hour.

Cetirizine is not effectively removed by dialysis.

Pharmacotherapeutic classification: Piperazine derivatives

R06A E07 (ATC classification system)

Cetirizine, a human metabolite of hydroxyzine, is a potent antihistamine, selective H1 receptor antagonist. The histamine-mediated 'early' phase of the allergic reaction is inhibited by cetirizine, which also reduces the migration of inflammatory cells and the release of mediators associated with the 'late' allergic responses. Effects on other receptors are negligible and consequently cetirizine is unlikely to cause undesirable anti-cholinergic and anti-serotonin effects. At the recommended therapeutic dose of 10 mg daily, impairment of CNS function has not been found to be greater than with the placebo.

In addition to its anti-H1 effect, cetirizine was shown to display anti-allergic activities: at a dose of 10 mg once or twice daily, it inhibits the late phase recruitment of eosinophils, in the skin and conjunctiva of atopic subjects submitted to allergen challenge.

Studies in healthy volunteers show that cetirizine, at doses of 5 mg and 10 mg strongly inhibits the wheal and flare reactions induced by very high concentrations of histamine into the skin, but the correlation with efficacy is not established.

In a 35-day study in children aged 5 to 12, no tolerance to the antihistaminic effect (suppression of the wheal and flare) of cetirizine was found. When a treatment with cetirizine is stopped after repeated administration, the skin recovers its normal reactivity to histamine within 3 days.

In a six-week, placebo-controlled study of 186 patients with allergic rhinitis and concomitant mild to moderate asthma, cetirizine 10 mg once daily improved rhinitis symptoms and did not alter pulmonary function. This study supports the safety of administering cetirizine to allergic patients with mild to moderate asthma.

In a placebo-controlled study, cetirizine given at the high daily dose of 60 mg for seven days did not cause statistically significant prolongation of the QT interval.

At the recommended dosage, cetirizine has demonstrated that it improves the quality of life of patients with perennial and seasonal allergic rhinitis.

Cetirizine is rapidly absorbed from the gastrointestinal tract; absorption is not reduced by food, though the rate may be decreased slightly. Peak blood levels in the order of 0.3 micrograms/ml are attained between 30 and 60 minutes following administration of a 10 mg oral dose of cetirizine. Apparent plasma clearance is greater in children than in adults: the terminal elimination half-life in healthy adult volunteers ranges between 6.7 – 10.7 hours; in children 6.1 – 7.1 hours; and in children aged under 4 years 5.55 hours. Cetirizine is mainly excreted unchanged in the urine (approximately 70% over 5 days compared with 10% in the faeces). The half-life is increased in renal dysfunction: half lives of 19 and 21 hours in patients with mild to moderate renal impairment respectively have been reported. This may have implications for elderly patients. Cetirizine binds strongly to plasma proteins.

Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential, toxicity to reproduction.

Propylene glycol

Glycerol

Methyl parahydroxybenzoate (E218)

Propyl parahydroxybenzoate (E216)

Sodium acetate

Acetic acid

Saccharin sodium

Liquid Sorbitol (E420)

Banana flavour (contains ethanol)

Purified water

None known.

Shelf life before opening – 36 months

Shelf life after opening – 6 months

Do not store above 25˚ C.

Type III amber glass bottles with a tamper evident screw cap having a polypropylene outer layer and a polyethylene inner layer.

Polystyrene/polyethylene measuring device.

60ml and 70ml

None.