For the treatment of chronic constipation in adults and children above the age of 12.

MOVICOL Chocolate is also effective in resolving faecal impaction, defined as refractory constipation with faecal loading of the rectum and/or colon.

Posology

Chronic Constipation

A course of treatment for constipation with Movicol Chocolate does not normally exceed two weeks, although this can be repeated if required.

As for all laxatives, prolonged use is not usually recommended. Extended use may be necessary in the care of patients with severe chronic or resistant constipation, secondary to multiple sclerosis or Parkinson's Disease, or induced by regular constipating medication, in particular opioids and antimuscarinics.

Adults, adolescents and older people: 1-3 sachets daily in divided doses, according to individual response.

For extended use, the dose can be adjusted down to 1 or 2 sachets daily.

Children under 12 years of age: Not recommended. Alternative Movicol products are available for children.

Faecal impaction

A course of treatment for faecal impaction with Movicol Chocolate does not normally exceed 3 days.

Adults, adolescents and older people: 8 sachets daily, all of which should be consumed within a 6 hour period.

Children under 12 years of age: Not recommended. Alternative Movicol products are available for children.

Patients with impaired cardiovascular function: For the treatment of faecal impaction the dose should be divided so that no more than two sachets are taken in any one hour.

Patients with renal insufficiency: No dosage change is necessary for treatment of either constipation or faecal impaction (see section 4.4 for warning about excipients)

Method of administration

Each sachet should be dissolved in 125ml water. For use in faecal impaction 8 sachets may be dissolved in 1 litre of water.

Intestinal perforation or obstruction due to structural or functional disorder of the gut wall, ileus, severe inflammatory conditions of the intestinal tract, such as Crohn's disease and ulcerative colitis and toxic megacolon.

Hypersensitivity to the active substances or to any of the excipients listed in section 6.1.

The fluid content of Movicol Chocolate when re-constituted with water does not replace regular fluid intake and adequate fluid intake must be maintained.

Diagnosis of impaction/ faecal loading of the rectum should be confirmed by physical or radiological examination of the abdomen and rectum.

If patients develop any symptoms indicating shifts of fluid/electrolytes (e.g. oedema, shortness of breath, increasing fatigue, dehydration, cardiac failure) Movicol Chocolate should be stopped immediately and electrolytes measured, and any abnormality should be treated appropriately.

The absorption of other medicinal products could transiently be reduced due to an increase in gastro-intestinal transit rate induced by Movicol Chocolate (see section 4.5).

Movicol Chocolate contains 14.1 mg benzyl alcohol per sachet. Benzyl alcohol may cause anaphylactoid reactions.

High volumes of benzyl alcohol should be used with caution and only if necessary, especially in subjects with kidney or liver impairment and during pregnancy/ breast feeding because of the risk of accumulation and toxicity (metabolic acidosis) of benzyl alcohol.

This medicinal product contains 8.125 mmol sodium per dose, equivalent to 9.3% of the WHO recommended maximum daily intake for sodium. When used long term for constipation, the maximum daily dose of this product is equivalent to 28% of the WHO recommended maximum daily intake for sodium. Movicol Chocolate is considered high in sodium. This should be particularly taken into account for those on a low salt diet.

In patients with swallowing problems, who need the addition of a thickener to solutions to enhance an appropriate intake, interactions should be considered, see section 4.5.

Clinical interactions with other drugs have been reported extremely rarely. No specific reactions with individual drugs or classes of drugs have been observed.

Macrogol raises the solubility of medicinal products that are soluble in alcohol and relatively insoluble in water (i.e. substances that have a hydrophilic and a hydrophobic pole in their molecular structure).

There is a possibility that the absorption of other medicinal products could be transiently reduced during use with Movicol Chocolate (see section 4.4). There have been isolated reports of decreased efficacy with some concomitantly administered medicinal products, e.g. anti-epileptics. Therefore, other medicines should not be taken orally for one hour before, during and for one hour after taking Movicol Chocolate.

Movicol Chocolate may result in a potential interactive effect if used with starch-based food thickeners. The Macrogol ingredient counteracts the thickening effect of starch, effectively liquefying preparations that need to remain thick for people with swallowing problems.

Pregnancy

There are limited amount of data from the use of MOVICOL in pregnant women. Studies in animals have shown indirect reproductive toxicity (see section 5.3). Clinically, no effects during pregnancy are anticipated, since systemic exposure to macrogol 3350 is negligible.

MOVICOL can be used during pregnancy.

Breastfeeding

No effects on the breastfed newborn/infant are anticipated since the systemic exposure of the breast-feeding woman to Macrogol 3350 is negligible.

MOVICOL can be used during breast-feeding.

Fertility

There are no data on the effects of MOVICOL on fertility in humans. There were no effects on fertility in studies in male and female rats (see section 5.3).

MOVICOL Chocolate has no influence on the ability to drive and use machines.

Reactions related to the gastrointestinal tract occur most commonly.

These reactions may occur as a consequence of expansion of the contents of the gastrointestinal tract, and an increase in motility due to the pharmacologic effects of MOVICOL. Mild diarrhoea usually responds to dose reduction.

The frequency of the adverse effects is not known as it cannot be estimated from the available data.

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 Yellow Card Scheme Website www.mhra.gov.uk/yellowcard.

Severe abdominal pain or distension can be treated by nasogastric aspiration. Extensive fluid loss by diarrhoea or vomiting may require correction of electrolyte disturbances.

Pharmacotherapeutic group: Osmotically acting laxatives.

ATC code: A06A D65

Macrogols are long linear polymers, also known as polyethylene glycols

Macrogol 3350 acts by virtue of its osmotic action in the gut, which induces a laxative effect. Macrogol 3350 increases the water content and hence the stool volume, which triggers colon motility via neuromuscular pathways. The physiological consequence is an improved propulsive colonic transportation of the softened stools and a facilitation of the defaecation. Electrolytes combined with macrogol 3350 are exchanged across the intestinal barrier (mucosa) with serum electrolytes and excreted in faecal water without net gain or loss of sodium, potassium and water.

For the indication of faecal impaction controlled comparative studies have not been performed with other treatments (e.g. enemas). In a non-comparative study in 27 adult patients, MOVICOL (parent product) cleared the faecal impaction in 12/27 (44%) after 1 day's treatment; 23/27 (85%) after 2 days' treatment and 24/27 (89%) at the end of 3 days.

Clinical studies in the use of MOVICOL (parent product) in chronic constipation have shown that the dose needed to produce normal formed stools tends to reduce over time. Many patients respond to between 1 and 2 sachets a day, but this dose should be adjusted depending on individual response.

Macrogol 3350 is unchanged along the gut. It is virtually unabsorbed from the gastro-intestinal tract. Any macrogol 3350 that is absorbed is excreted via the urine.

Preclinical studies provide evidence that macrogol 3350 has no significant systemic toxicity potential, based on conventional studies of pharmacology, repeated dose toxicity and genotoxicity.

There were no direct embryotoxic or teratogenic effects in rats even at maternally toxic levels that are a multiple of 66 x the maximum recommended dose in humans for chronic constipation and 25 x for faecal impaction. Indirect embryofetal effects, including reduction in fetal and placental weights, reduced fetal viability, increased limb and paw hyperflexion and abortions, were noted in the rabbit at a maternally toxic dose that was 3.3 x the maximum recommended dose in humans for treatment of chronic constipation and 1.3 x for faecal impaction. Rabbits are a sensitive animal test species to the effects of GI-acting substances and the studies were conducted under exaggerated conditions with high dose volumes administered, which are not clinically relevant. The findings may have been a consequence of an indirect effect of MOVICOL related to poor maternal condition as the result of an exaggerated pharmacodynamic response in the rabbit. There was no indication of a teratogenic effect.

There are long-term animal toxicity and carcinogenicity studies involving macrogol 3350. Results from these and other toxicity studies using high levels of orally administered high molecular weight macrogols provide evidence of safety at the recommended therapeutic dose.

Acesulfame Potassium (E950)

Chocolate Flavour (contains maltodextrin (potato), gum arabic/acacia gum E414, vegetable oils and fats (coconut), propylene glycol E1520, and benzyl alcohol E1519)

MOVICOL Chocolate contains 186.87 mg (8.125 mmol) sodium (main component of cooking/table salt) per sachet. This is equivalent to 9.3% of the recommended maximum daily dietary intake of sodium for an adult.

None are known.

3 years

Reconstituted solution: 6 hours.

Sachet: This medicinal product does not require any special storage conditions.

Reconstituted solution: Store at 2° C – 8° C (in a refrigerator and keep covered).

Sachet: laminate consisting of four layers: low density polyethylene, aluminium, low density polyethylene and paper.

Pack sizes: boxes of 20 or 30 sachets.

Not all pack sizes may be marketed.

Any unused solution should be discarded within 6 hours. Any unused medicinal product or waste material should be disposed of in accordance with local requirements.