Day Nurse Capsules

For the relief of the symptoms of colds and influenza. For oral administration.

Take during the day.

Should not be used with other paracetamol-containing products, decongestants or cough and cold medicines.

Adults and Children over 16 years

Two capsules every four hours, up to a maximum of 4 doses in 24 hours if needed, or up to a maximum of three doses within any 24 hour period if a night-time paracetamol-containing product is taken before bedtime. Minimum dosing interval: 4 hours. Do not exceed the stated dose. Do not use for longer than 7 days unless your doctor agrees.

Use the lowest amount needed to achieve benefit for the shortest duration of treatment.

Children under 16 years

Not to be given to children under sixteen years of age.

Elderly

There is no specific requirement for dosage reduction in the elderly.

The product is contraindicated in patients with:

• Hypersensitivity to any of the ingredients or excipients.

• Severe hypertension or coronary artery disease.

• Severe renal impairment.

• Hyperexcitability.

• With or at risk of developing, respiratory failure (e.g. those with chronic obstructive airways disease or pneumonia) or those with bronchiolitis or bronchiectasis due to sputum retention.

• Who are receiving other sympathomimetics (such as decongestants, appetite suppressants and amphetamine-like medicines).

• Who are receiving Monoamine Oxidase Inhibitors (MAOIs) or for two weeks after stopping a MAOI drug.

• Who are taking oxazolidinone class of antibiotics (including linezolid).

• In patients taking beta-blockers and other antihypertensives.

Should be given with caution to patients with mild to moderate kidney impairment and in those with impaired liver function. The hazard of overdose is greater in those with non-cirrhotic alcoholic liver disease. Overdose may cause liver failure, which may require liver transplant or lead to death.

The product should be discontinued immediately, and medical advice should be sought:

• If sudden abdominal pain, rectal bleeding or other symptoms of ischaemic colitis develop as there have been reports of ischaemic colitis with pseudoephedrine.

• There have been rare cases of posterior reversible encephalopathy (PRES)/reversible cerebral vasoconstriction syndrome (RCVS) reported with sympathomimetic drugs, including pseudoephedrine. Symptoms reported included sudden onset of severe headache, nausea, vomiting, and visual disturbances. Most cases improved or resolved within a few days following appropriate treatment. Pseudoephedrine should be discontinued immediately, and medical advice sought if signs/symptoms of PRES/RCVS develop.

Cases of ischaemic optic neuropathy have been reported with pseudoephedrine. Pseudoephedrine should be discontinued if sudden loss of vision or decreased visual acuity such as scotoma occurs.

Severe skin reactions such as acute generalized exanthematous pustulosis (AGEP) may occur with pseudoephedrine-containing products. This acute pustular eruption may occur within the first 2 days of treatment, with fever, and numerous, small, mostly non-follicular pustules arising on a widespread oedematous erythema and mainly localized on the skin folds, trunk, and upper extremities. Patients should be carefully monitored. If signs and symptoms such as pyrexia, erythema, or many small pustules are observed, administration of Day Nurse Capsules should be discontinued, and appropriate measures taken if needed.

Medical advice should be sought before taking this product in patients with:

• glutathione depletion due to metabolic deficiencies

• psychosis

• cardiovascular disease

• arrhythmias

• hypertension

• hyperthyroidism

• prostatic enlargement

• diabetes

• glaucoma

• phaeochromocytoma

• chronic or persistent cough, asthma, or where cough is accompanied by excessive secretions

• taking tricyclic antidepressants

Use with caution:

• in patients taking vasoconstrictive agents such as ergot alkaloids

• when planning surgery. Acute perioperative hypertension may occur if volatile halogenated anaesthetics are used simultaneously with indirect sympathomimetic agents. It is recommended that pseudoephedrine treatment is stopped for several days before anaesthesia.

• in patients taking other CNS depressants (including alcohol). Pholcodine may enhance the CNS effects of alcohol and other CNS depressants.

Severe cutaneous adverse reactions (SCARs) including acute generalized exanthematous pustulosis (AGEP) may occur with pholcodine-containing products. These can be life-threatening or fatal, have been reported in patients treated with Day Nurse, most likely in the first week. Patients should be advised of the signs and symptoms and monitored closely for skin reactions. If signs and symptoms suggestive of these reactions appear, Day Nurse should be discontinued immediately.

Caution is needed in patients with a history of drug abuse. Pholcodine is an opioid and addiction is observed with opioids as a class.

Pseudoephedrine content of this product may result in a positive reaction during antidoping control tests.

Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this product.

Contains paracetamol.

Warning: Do not exceed the stated dose.

Asthmatics should consult their doctor before using this product.

If symptoms persist, consult your doctor.

Do not take with any other paracetamol-containing products. Do not take with any other flu, cold or decongestant products.

Keep out of reach and sight of children.

Label

Immediate medical advice should be sought in the case of an overdose, even if you feel well.

Leaflet or combined label/leaflet

Immediate medical advice should be sought in the event of an overdose, even if you feel well, because of the risk of delayed, serious liver damage.

Should not be given to patients being treated with monoamine oxidase inhibitors or within 14 days of stopping such treatment as this may lead to a hypertensive crisis.

Pseuodephedrine may diminish the antihypertensive effects of beta blockers and other antihypertensive drugs.

Pseudoephedrine may interact with halogenated anaesthetics.

Patients taking concomitant vasoconstrictive agents (including ergot derivatives) should be monitored for signs and symptoms of ergotism.

Pholcodine may enhance the sedative effect of central nervous system depressants including alcohol, barbiturates, hypnotics, narcotic analgesics, sedatives and tranquillisers. Pholcodine may also predispose patients to developing anaphylaxis with neuromuscular blocking agents.

Concomitant use of this medication with sympathomimetic agents (such as decongestants, tricyclic antidepressants, appetite suppressants and amphetamine-like medicines) which interfere with the catabolism of sympathomimietic amines, may occasionally cause a rise in blood pressure.

The oxazolidinone class of antibiotics (including linezolid) are known to cause a dose-related inhibition of monoamine oxidase.

Therefore they should not be taken with Day Nurse Capsules as there is a potential to cause hypertensive crisis

The speed of absorption of paracetamol may be increased by metoclopramide or domperidone and absorption reduced by colestyramine.

The anticoagulant effect of warfarin and other coumarins may be enhanced by prolonged regular daily use of paracetamol with increased risk of bleeding, occasional doses have no significant effect.

Safe use of pseudoephedrine and pholcodine in pregnancy has not been established despite widespread use over many years. Caution should therefore be exercised by balancing the potential benefit of treatment to the mother against any possible hazards to the developing foetus.

In view of the possible association of foetal abnormalities with first trimester exposure to pseudoephedrine this product should not be used in pregnancy without medical advice. If used, the lowest effective dose and shortest duration of treatment should be considered.

Pseudoephedrine is excreted in breast milk in small amounts but the effect of this on breast fed infants is unknown. The safety of the ingredients during lactation has not been established . Therefore, the use of the product during lactation should only be on medical advice, and only if the benefits to the mother outweigh the risks to the infant. If used, the lowest effective dose and shortest duration of treatment should be considered

Patients should be advised not to drive or operate machinery if affected by dizziness.

The following convention has been utilised or the classification of undesirable effects: very common (>/=1/10), common (>=1/100. <1/10), uncommon (<=1/1000,<1/100), rare (<=1/10000, <1/1000), very rare (1</10000).

Paracetamol

Adverse events of paracetamol from historical clinical trial data are both infrequent and from small patient exposure. Accordingly, events reported from extensive post-marketing experience at therapeutic/labelled dose and considered attributable are tabulated below by system class. The frequency of these adverse is not known (cannot be estimated from available data).

Pseudoephedrine

The frequency of reactions identified during post-marketing use is not known.

*Increases in systolic blood pressure have been observed. At therapeutic doses, the effects of pseudoephedrine on blood pressure are not clinically significant.

**A variety of allergic skin reactions, with or without systemic features such as bronchospasm and angioedema have been reported following use of pseudoephedrine.

***Urinary retention is most likely to occur in those with bladder outlet obstruction, such as prostatic hypertrophy.

Pholcodine

The frequency of reactions identified during post-marketing use is not known.

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.

Paracetamol

Liver damage is possible in adults who have taken 10g or more of paracetamol. Ingestion of 5g or more of paracetamol may lead to liver damage if the patient has risk factors (see below).

Risk factors: If the patient

a. Is on long term treatment with carbamazepine, phenobarbitone, phenytoin, primidone, rifampicin, St John's Wort or other drugs that induce liver enzymes. Or

b. Regularly consumes ethanol in excess of recommended amounts. Or

c. Is likely to be glutathione deplete e.g. eating disorders, cystic fibrosis, HIV infection, starvation, cachexia.

Symptoms:

Symptoms of paracetamol overdosage in the first 24 hours are pallor, nausea, vomiting, anorexia and abdominal pain. Liver damage may become apparent 12 to 48 hours after ingestion. Abnormalities of glucose metabolism and metabolic acidosis may occur. In severe poisoning, hepatic failure may progress to encephalopathy, haemorrhage, hypoglycaemia, cerebral oedema, and death. Acute renal failure with acute tubular necrosis, strongly suggested by loin pain, haematuria and proteinuria, may develop even in the absence of severe liver damage. Cardiac arrhythmias and pancreatitis have been reported.

Management:

Immediate treatment is essential in the management of paracetamol overdose.

Despite a lack of significant early symptoms, patients should be referred to hospital urgently for immediate medical attention. Symptoms may be limited to nausea or vomiting and may not reflect the severity of overdose or the risk of organ damage. Management should be in accordance with established treatment guidelines, see BNF overdose section.

Treatment with activated charcoal should be considered if the overdose has been taken within 1 hour. Plasma paracetamol concentration should be measured at 4 hours or later after ingestion (earlier concentrations are unreliable). Treatment with N-acetylcysteine may be used up to 24 hours after ingestion of paracetamol, however, the maximum protective effect is obtained up to 8 hours post-ingestion. The effectiveness of the antidote declines sharply after this time. If required the patient should be given intravenous N- acetylcysteine, in line with the established dosage schedule. If vomiting is not a problem, oral methionine may be a suitable alternative for remote areas, outside hospital. Management of patients who present with serious hepatic dysfunction beyond 24h from ingestion should be discussed with the NPIS or a liver unit.

Pseudoephedrine Hydrochloride

Symptoms:

As with other sympathomimetics pseudoephedrine overdose will result in symptoms due to central nervous system and cardiovascular stimulation e.g. excitement, irritability, restlessness, tremor, hallucinations, hypertension, palpitations, arrhythmias and difficulty with micturition. In severe cases, psychosis, convulsions, coma and hypertensive crisis may occur. Serum potassium levels may be low due to extracellular to intracellular shifts in potassium.

Management:

Treatment should consist of standard supportive measures. Beta-blockers should reverse the cardiovascular complications and the hypokalaemia.

Pholcodine

The effects of overdosage will be potentiated by simultaneous ingestion of alcohol and psychotropic drugs.

Symptoms:

Central nervous system depression, including respiratory depression, may develop but is unlikely to be severe unless other sedative agents have been co- ingested, including alcohol, or the overdose is very large. The pupils may be pin-point in size; nausea and vomiting are common. Hypotension and tachycardia are possible but unlikely.

Management:

This should include general symptomatic and supportive measures including a clear airway and monitoring of vital signs until stable. Consider activated charcoal if an adult presents within one hour of ingestion of more than 350 mg or a child more than 5 mg/kg.

Give naloxone if coma or respiratory depression is present. Naloxone is a competitive antagonist and has a short half-life, so large and repeated doses may be required in a seriously poisoned patient. Observe for at least four hours after ingestion, or eight hours if a sustained release preparation has been taken.

Paracetamol has analgesic and antipyretic actions.

Pseudoephedrine is a sympathomimetic agent with both direct and indirect effects on adrenergic receptors. Pholcodine is a cough suppressant with little analgesic activity.

Paracetamol is readily absorbed from the gastrointestinal tract with peak plasma concentrations occurring about 30 minutes to 2 hours after oral administration. Paracetamol is distributed into most body tissues. It crosses the placenta and is present in breast milk. Plasma protein binding is negligible at usual therapeutic concentrations. Paracetamol is metabolised predominantly in the liver and excreted in the urine mainly as the glucuronide and sulphate conjugates, with about 10% as glutathione conjugates. Less than 5% is excreted as unchanged paracetamol. The elimination half life varies from about 1 to 4 hours.

Pseudoephedrine is absorbed from the gastrointestinal tract. It is resistant to metabolism and is excreted largely unchanged in the urine. It has a half life of several hours but elimination is enhanced and half life shortened in acid urine.

Pholcodine is rapidly absorbed after oral administration and maximum plasma concentrations are attained at about 4-8 hours. The elimination half life ranges from 32 to 43 hours. The drug has a large volume of distribution and is only 23.5% protein bound. Pholcodine is metabolised in the liver but undergoes little conjugation with glucuronide and sulphate.

There are no preclinical data of relevance to the prescriber which are additional to that already included.

Sodium lauryl sulphate Sodium starch glycollate Magnesium stearate E572

Hard gelatin capsule

(containing: Quinoline yellow E104, Allura red E 129, Titanium dioxide E171)

Printing Ink: Opacode black

(containing: shellac, iron oxide black (E172), propylene glycol (E1520), ammonium hydroxide (E527)).

Not applicable

36 months

Do not store above 25° C. Store in the original package.

250μ m PVC/60gsm PVDC blister tray with 30μ m aluminium foil lid in a cardboard carton containing 8, 10, 12, 16, 20, 24 or 32 tablets. Not all pack sizes may be marketed.

Not applicable.