Moxifloxacin (as moxifloxacin hydrochloride) .... 400 mg
Excipients q.s …………… 1 tablet
Film coated tablet.
Product description: A salmon-colored, capsule-shaped, film-coated tablet, plain on one side, scored on the other side, undamaged edges.
Box of 1 blister x 10 film-coated tablets.
Pharmacotherapeutic group: Fluoroquinolone antibacterials. ATC code: J01 MA14
Mechanism of action
MOLOXCIN 400 film-coated tablet contains the active ingredient Moxifloxacin which has in vitro activity against a wide range of Gram-positive and Gram-negative pathogens.
The bactericidal action of moxifloxacin results from the inhibition of both type II topoisomerases (DNA gyrase and topoisomerase IV) required for bacterial DNA replication, transcription and repair. It appears that the C8-methoxy moiety contributes to enhanced activity and lower selection of resistant mutants of Gram-positive bacteria compared to the C8-H moiety. The presence of the bulky bicycloamine substituent at the C-7 position prevents active efflux, associated with the norA or pmrA genes seen in certain Gram-positive bacteria.
Pharmacodynamic investigations have demonstrated that moxifloxacin exhibits a concentration dependent killing rate. Minimum bactericidal concentrations (MBC) were found to be in the range of the minimum inhibitory concentrations (MIC).
Effect on the intestinal flora in humans
The following changes in the intestinal flora were seen in volunteers following oral administration of moxifloxacin: Escherichia coli, Bacillus spp., Enterococcus spp., and Klebsiella spp. were reduced, as were the anaerobes Bacteroides vulgatus, Bifidobacterium spp., Eubacterium spp., and Peptostreptococcus spp.
For Bacteroides fragilis there was an increase. These changes returned to normal within two weeks.
Mechanism of resistance.
Resistance mechanisms that inactivate penicillins, cephalosporins, aminoglycosides, macrolides and tetracyclines do not interfere with the antibacterial activity of moxifloxacin. Other resistance mechanisms such as permeation barriers (common in Pseudomonas aeruginosa) and efflux mechanisms may also effect susceptibility to moxifloxacin.
In vitro resistance to moxifloxacin is acquired through a stepwise process by target site mutations in both type II topoisomerases, DNA gyrase and topoisomerase IV. Moxifloxacin is a poor substrate for active efflux mechanisms in Gram-positive organisms.
Cross-resistance is observed with other fluoroquinolones. However, as moxifloxacin inhibits both topoisomerase II and IV with similar activity in some Gram-positive bacteria, such bacteria may be resistant to other quinolones, but susceptible to moxifloxacin.
Breakpoints
EUCAST clinical MIC and disk diffusion breakpoints for moxifloxacin (v. 9.0, 01 January 2019):
Microbiological susceptibility
The prevalence of acquired resistance may vary geographically and with time for selected species and local information of resistance is desirable, particularly when treating severe infections. As necessary, expert advice should be sought where the local prevalence of resistance is such that utility of the agent in at least some types of infections is questionable.
Absorption and Bioavailability
Following oral administration moxifloxacin is rapidly and almost completely absorbed. The absolute bioavailability amounts to approximately 91%.
Pharmacokinetics are linear in the range of 50 - 800 mg single dose and up to 600 mg once daily dosing over 10 days. Following a 400 mg oral dose peak concentrations of 3.1 mg/l are reached within 0.5 - 4 h post administration. Peak and trough plasma concentrations at steady-state (400 mg once daily) were 3.2 and 0.6 mg/l, respectively. At steady state the exposure within the dosing interval is approximately 30% higher than after the first dose.
Distribution
Moxifloxacin is distributed to extravascular spaces rapidly; after a dose of 400 mg an AUC of 35 mg∙h/l is observed. The steady-state volume of distribution (Vss) is approximately 2 l/kg. In vitro and ex vivo experiments showed a protein binding of approximately 40 - 42% independent of the concentration of the drug. Moxifloxacin is mainly bound to serum albumin.
The following peak concentrations (geometric mean) were observed following administration of a single dose of 400 mg moxifloxacin:
Biotransformation
Moxifloxacin undergoes Phase II biotransformation and is excreted via renal and biliary/faecal pathways as unchanged drug as well as in the form of a sulpho-compound (M1) and a glucuronide (M2). M1 and M2 are the only metabolites relevant in humans, both are microbiologically inactive.
In clinical Phase I and in vitro studies no metabolic pharmacokinetic interactions with other drugs undergoing Phase I biotransformation involving cytochrome P450 enzymes were observed. There is no indication of oxidative metabolism.
Elimination
Moxifloxacin is eliminated from plasma with a mean terminal half life of approximately 12 hours. The mean apparent total body clearance following a 400 mg dose ranges from 179 to 246 ml/min. Renal clearance amounted to about 24 - 53 ml/min suggesting partial tubular reabsorption of the drug from the kidneys.
After a 400 mg dose, recovery from urine (approximately 19% for unchanged drug, approximately 2.5% for M1, and approximately 14% for M2), and faeces (approximately 25% of unchanged drug, approximately 36% for M1, and no recovery for M2) totalled to approximately 96%.
Concomitant administration of moxifloxacin with ranitidine or probenecid did not alter renal clearance of the parent drug.
Elderly and patients with low body weight
Higher plasma concentrations are observed in healthy volunteers with low body weight (such as women) and in elderly volunteers.
Renal impairment
The pharmacokinetic properties of moxifloxacin are not significantly different in patients with renal impairment (including creatinine clearance > 20 ml/min/1.73 m2). As renal function decreases, concentrations of the M2 metabolite (glucuronide) increase by up to a factor of 2.5 (with a creatinine clearance of < 30 ml/min/1.73 m2).
Hepatic impairment
On the basis of the pharmacokinetic studies carried out so far in patients with liver failure (Child Pugh A, B), it is not possible to determine whether there are any differences compared with healthy volunteers. Impaired liver function was associated with higher exposure to M1 in plasma, whereas exposure to parent drug was comparable to exposure in healthy volunteers. There is insufficient experience in the clinical use of moxifloxacin in patients with impaired liver function.
Preclinical safety data
Effects on the haematopoetic system (slight decreases in the number of erythrocytes and platelets) were seen in rats and monkeys. As with other quinolones, hepatotoxicity (elevated liver enzymes and vacuolar degeneration) was seen in rats, monkeys and dogs. In monkeys, CNS toxicity (convulsions) occurred. These effects were seen only after treatment with high doses of moxifloxacin or after prolonged treatment.
Moxifloxacin, like other quinolones, was genotoxic in in vitro tests using bacteria or mammalian cells. Since these effects can be explained by an interaction with the gyrase in bacteria and - at higher concentrations - by an interaction with the topoisomerase II in mammalian cells, a threshold concentration for genotoxicity can be assumed. In in vivo tests, no evidence of genotoxicity was found despite the fact that very high moxifloxacin doses were used. Thus, a sufficient margin of safety to the therapeutic dose in man can be provided. Moxifloxacin was non-carcinogenic in an initiation-promotion study in rats.
Many quinolones are photoreactive and can induce phototoxic, photomutagenic and photocarcinogenic effects. In contrast, moxifloxacin was proven to be devoid of phototoxic and photogenotoxic properties when tested in a comprehensive programme of in vitro and in vivo studies. Under the same conditions other quinolones induced effects.
At high concentrations, moxifloxacin is an inhibitor of the rapid component of the delayed rectifier potassium current of the heart and may thus cause prolongations of the QT interval. Toxicological studies performed in dogs using oral doses of ≥ 90 mg/kg leading to plasma concentrations ≥ 16 mg/l caused QT prolongations, but no arrhythmias. Only after very high cumulative intravenous administration of more than 50-fold the human dose (> 300 mg/kg), leading to plasma concentrations of ≥ 200 mg/l (more than 40-fold the therapeutic level), reversible, non-fatal ventricular arrhythmias were seen.
Quinolones are known to cause lesions in the cartilage of the major diarthrodial joints in immature animals. The lowest oral dose of moxifloxacin causing joint toxicity in juvenile dogs was four times the maximum recommended therapeutic dose of 400 mg (assuming a 50 kg body-weight) on a mg/kg basis, with plasma concentrations two to three times higher than those at the maximum therapeutic dose.
Toxicity tests in rats and monkeys (repeated dosing up to six months) revealed no indication regarding an oculotoxic risk. In dogs, high oral doses (≥ 60 mg/kg) leading to plasma concentrations ≥ 20 mg/l caused changes in the electroretinogram and in isolated cases an atrophy of the retina.
Reproductive studies performed in rats, rabbits and monkeys indicate that placental transfer of moxifloxacin occurs. Studies in rats (p.o. and i.v.) and monkeys (p.o.) did not show evidence of teratogenicity or impairment of fertility following administration of moxifloxacin. A slightly increased incidence of vertebral and rib malformations was observed in foetuses of rabbits but only at a dose (20 mg/kg i.v.) which was associated with severe maternal toxicity. There was an increase in the incidence of abortions in monkeys and rabbits at human therapeutic plasma concentrations. In rats, decreased foetal weights, an increased prenatal loss, a slightly increased duration of pregnancy and an increased spontaneous activity of some male and female offspring was observed at doses which were 63 times the maximum recommended dose on a mg/kg basis with plasma concentrations in the range of the human therapeutic dose.
No studies on the effects of moxifloxacin on the ability to drive and use machines have been performed. However, fluoroquinolones including moxifloxacin may result in an impairment of the patient's ability to drive or operate machinery due to CNS reactions (e.g. dizziness; acute, transient loss of vision, see section Undesirable effects) or acute and short lasting loss of consciousness (syncope, see section Undesirable effects). Patients should be advised to see how they react to moxifloxacin before driving or operating machinery.
Disabling and potentially irreversible serious adverse reactions including tendinitis and tendon rupture, peripheral neuropathy, and central nervous system effects.
Fluoroquinolones have been associated with disabling and potentially irreversible serious adverse reactions from different body systems that can occur together in the same patient. Commonly seen adverse reactions include tendinitis, tendon rupture, arthralgia, myalgia, peripheral neuropathy, and central nervous system effects (hallucinations, anxiety, depression, insomnia, severe headaches, and confusion). These reactions can occur within hours to weeks after starting moxifloxacin. Patients of any age or without pre-existing risk factors have experienced these adverse reactions.
Discontinue moxifloxacin immediately at the first signs or symptoms of any serious adverse reaction. In addition, avoid the use of fluoroquinolones in patients who have experienced any of these serious adverse reactions associated with fluoroquinolones.
The use of moxifloxacin should be avoided in patients who have experienced serious adverse reactions in the past when using quinolone or fluoroquinolone containing products (see section Undesirable effects). Treatment of these patients with moxifloxacin should only be initiated in the absence of alternative treatment options and after careful benefit-risk assessment (see also section Contraindications).
The benefit of moxifloxacin treatment especially in infections with a low degree of severity should be balanced with the information contained in the warnings and precautions section.
Prolonged, disabling and potentially irreversible serious adverse drug reactions
Very rare cases of prolonged (continuing months or years), disabling and potentially irreversible serious adverse drug reactions affecting different, sometimes multiple, body systems (musculoskeletal, nervous, psychiatric and senses) have been reported in patients receiving quinolones and fluoroquinolones irrespective of their age and pre-existing risk factors. Moxifloxacin should be discontinued immediately at the first signs or symptoms of any serious adverse reaction and patients should be advised to contact their prescriber for advice.
Prolongation of QTc interval and potentially QTc-prolongation-related clinical conditions
Moxifloxacin has been shown to prolong the QTc interval on the electrocardiogram in some patients. In the analysis of ECGs obtained in the clinical trial program, QTc prolongation with moxifloxacin was 6 msec ± 26 msec, 1.4% compared to baseline. As women tend to have a longer baseline QTc interval compared with men, they may be more sensitive to QTc-prolonging medications. Elderly patients may also be more susceptible to drug-associated effects on the QT interval.
Medication that can reduce potassium levels should be used with caution in patients receiving moxifloxacin (see sections Contraindications and Interactions).
Moxifloxacin should be used with caution in patients with ongoing proarrhythmic conditions (especially women and elderly patients), such as acute myocardial ischaemia or QT prolongation as this may lead to an increased risk for ventricular arrhythmias (including torsade de pointes) and cardiac arrest (see also section Contraindications). The magnitude of QT prolongation may increase with increasing concentrations of the drug. Therefore, the recommended dose should not be exceeded.
If signs of cardiac arrhythmia occur during treatment with moxifloxacin, treatment should be stopped and an ECG should be performed.
Aortic aneurysm and dissection, and heart valve regurgitation/incompetence
Epidemiologic studies report an increased risk of aortic aneurysm and dissection, particularly in elderly patients, and of aortic and mitral valve regurgitation after intake of fluoroquinolones, Cases of aortic aneurysm and dissection, sometimes complicated by rupture (including fatal ones), and of regurgitation/incompetence of any of the heart valves have been reported in patients receiving fluoroquinolones (see section Undesirable effects).
Therefore, fluoroquinolones should only be used after careful benefit-risk assessment and after consideration of other therapeutic options in patients with positive family history of aneurysm disease or congenital heart valve disease, or in patients diagnosed with pre-existing aortic aneurysm and/or aortic dissection, or heart valve disease or in presence of other risk factors or conditions predisposing
• for both aortic aneurysm and dissection and heart valve regurgitation/incompetence (e.g. connective tissue disorders such as Marfan syndrome or Ehlers-Danlos syndrome, Turner syndrome, Behcet's disease, hypertension, rheumatoid arthritis or additionally
• for aortic aneurysm and dissection (e.g. vascular disorders such as Takayasu arteritis or giant cell arteritis, or known atherosclerosis, or Sjögren's syndrome) or
• additionally for heart valve regurgitation/incompetence (e.g. infective endocarditis).
The risk of aortic aneurysm and dissection, and their rupture may also be increased in patients treated concurrently with systemic corticosteroids.
In case of sudden abdominal, chest or back pain, patients should be advised to immediately consult a physician in an emergency department.
Patients should be advised to seek immediate medical attention in case of acute dyspnoea, new onset of heart palpitations, or development of oedema of the abdomen or lower extremities.
Hypersensitivity/allergic reactions
Hypersensitivity and allergic reactions have been reported for fluoroquinolones including moxifloxacin after first administration. Anaphylactic reactions can progress to a life-threatening shock, even after the first administration. In cases of clinical manifestations of severe hypersensitivity reactions moxifloxacin should be discontinued and suitable treatment (e.g. treatment for shock) initiated.
Severe liver disorders
Cases of fulminant hepatitis potentially leading to liver failure (including fatal cases) have been reported with moxifloxacin (see section Undesirable effects). Patients should be advised to contact their doctor prior to continuing treatment if signs and symptoms of fulminant hepatic disease develop such as rapidly developing asthenia associated with jaundice, dark urine, bleeding tendency or hepatic encephalopathy.
Liver function tests/investigations should be performed in cases where indications of liver dysfunction occur.
Severe cutaneous adverse reactions
Severe cutaneous adverse reactions (SCARs) including toxic epidermal necrolysis (TEN: also known as Lyell's syndrome), Stevens Johnson syndrome (SJS) and Acute Generalised Exanthematous Pustulosis (AGEP), which could be life-threatening or fatal, have been reported with moxifloxacin (see section Undesirable effects). At the time of prescription, patients should be advised of the signs and symptoms of severe skin reactions and be closely monitored. If signs and symptoms suggestive of these reactions appear, moxifloxacin should be discontinued immediately, and an alternative treatment should be considered. If the patient has developed a serious reaction such as SJS, TEN or AGEP with the use of moxifloxacin, treatment with moxifloxacin must not be restarted in this patient at any time.
Patients predisposed to seizures
Quinolones are known to trigger seizures. Use should be with caution in patients with CNS disorders or in the presence of other risk factors which may predispose to seizures or lower the seizure threshold. In case of seizures, treatment with moxifloxacin should be discontinued and appropriate measures instituted.
Peripheral neuropathy
Cases of sensory or sensorimotor polyneuropathy resulting in paraesthesia, hypoaesthesia, dysaesthesia, or weakness have been reported in patients receiving quinolones and fluoroquinolones . Patients under treatment with moxifloxacin should be advised to inform their doctor prior to continuing treatment if symptoms of neuropathy such as: pain, burning, tingling, numbness, or weakness develop in order to prevent the development of potentially irreversible condition (see section Undesirable effects).
Psychiatric reactions
Psychiatric reactions may occur even after the first administration of quinolones, including moxifloxacin. In very rare cases depression or psychotic reactions have progressed to suicidal thoughts and self-injurious behaviour such as suicide attempts (see section Undesirable effects). In the event that the patient develops these reactions, moxifloxacin should be discontinued and appropriate measures instituted. Caution is recommended if moxifloxacin is to be used in psychotic patients or in patients with history of psychiatric disease.
Antibiotic-associated diarrhoea including colitis
Antibiotic-associated diarrhoea (AAD) and antibiotic-associated colitis (AAC), including pseudomembranous colitis and Clostridium difficile-associated diarrhoea, has been reported in association with the use of broad-spectrum antibiotics including moxifloxacin and may range in severity from mild diarrhoea to fatal colitis. Therefore it is important to consider this diagnosis in patients who develop serious diarrhoea during or after the use of moxifloxacin.
If AAD or AAC is suspected or confirmed, ongoing treatment with antibacterial agents, including moxifloxacin, should be discontinued and adequate therapeutic measures should be initiated immediately. Furthermore, appropriate infection control measures should be undertaken to reduce the risk of transmission. Drugs inhibiting peristalsis are contraindicated in patients who develop serious diarrhoea.
Patients with myasthenia gravis
Moxifloxacin should be used with caution in patients with myasthenia gravis because the symptoms can be exacerbated.
Tendinitis and tendon rupture
Tendinitis and tendon rupture (especially but not limited to the Achilles tendon), sometimes bilateral, may occur as early as within 48 hours of starting treatment with quinolones and fluoroquinolones, and have been reported to occur even up to several months after discontinuation of treatment (see sections Contraindications; Undesirable effects). The risk of tendinitis and tendon rupture is increased in older patients, patients with renal impairment, patients with solid organ transplants, and those treated concurrently with corticosteroids. Therefore, concomitant use of corticosteroids should be avoided.
At the first sign of tendinitis (e.g. painful swelling, inflammation) the treatment with moxifloxacin should be discontinued and alternative treatment should be considered. The affected limb(s) should be appropriately treated (e.g., immobilisation). Corticosteroids should not be used if signs of tendinopathy occur.
Patients with renal impairment
Elderly patients with renal disorders should use moxifloxacin with caution if they are unable to maintain adequate fluid intake, because dehydration may increase the risk of renal failure.
Vision disorders
If vision becomes impaired or any effects on the eyes are experienced, an eye specialist should be consulted immediately (see sections Effects on ability to drive and use machines; Undesirable effects).
Dysglycaemia
As with all quinolones, disturbances in blood glucose, including both hypoglycaemia and hyperglycaemia have been reported (see section Undesirable effects), usually in diabetic patients receiving concomitant treatment with an oral hypoglycaemic agent (e.g., glibenclamide) or with insulin. Cases of hypoglycaemic coma have been reported. In diabetic patients, careful monitoring of blood glucose is recommended.
Prevention of photosensitivity reactions
Quinolones have been shown to cause photosensitivity reactions in patients. However, studies have shown that moxifloxacin has a lower risk to induce photosensitivity. Nevertheless patients should be advised to avoid exposure to either UV irradiation or extensive and/or strong sunlight during treatment with moxifloxacin.
Patients with glucose-6-phosphate dehydrogenase deficiency
Patients with a family history of, or actual glucose-6-phosphate dehydrogenase deficiency are prone to haemolytic reactions when treated with quinolones. Therefore, moxifloxacin should be used with caution in these patients.
Patients with pelvic inflammatory disease
For patients with complicated pelvic inflammatory disease (e.g. associated with a tubo-ovarian or pelvic abscess), for whom an intravenous treatment is considered necessary, treatment with moxifloxacin is not recommended.
Pelvic inflammatory disease may be caused by fluoroquinolone-resistant Neisseria gonorrhoeae. Therefore in such cases empirical moxifloxacin should be co-administered with another appropriate antibiotic (e.g. a cephalosporin) unless moxifloxacin-resistant Neisseria gonorrhoeae can be excluded. If clinical improvement is not achieved after 3 days of treatment, the therapy should be reconsidered.
Patients with a special cSSSI
Clinical efficacy of intravenous moxifloxacin in the treatment of severe burn wound infections, fasciitis, and diabetic foot infection with osteomyelitis has not been established.
Interference with biological tests
Moxifloxacin therapy may interfere with the Mycobacterium spp. culture test by suppression of mycobacterial growth causing false negative results in samples taken from patients currently receiving moxifloxacin.
Patients with MRSA infections
Moxifloxacin is not recommended for the treatment of MRSA infections. In case of a suspected or confirmed infection due to MRSA, treatment with an appropriate antibacterial agent should be started (see section Pharmacodynamic properties).
Paediatric population
Due to adverse effects on the cartilage in juvenile animals (see section Preclinical safety data) the use of moxifloxacin in children and adolescents < 18 years is contraindicated (see section Contraindications).
Excipients
Lactose monohydrate: Patients with problems of galactose intolerance, lactase deficiency or glucose-galactose malabsorption should not take this medicine.
This medicine contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially “sodium-free”.
Pregnancy
The safety of moxifloxacin in human pregnancy has not been evaluated. Animal studies have shown reproductive toxicity (see section Preclinical safety data). The potential risk for humans is unknown. Due to the experimental risk of damage by fluoroquinolones to the weight-bearing cartilage of immature animals and reversible joint injuries described in children receiving some fluoroquinolones, moxifloxacin must not be used in pregnant women (see section Contraindications).
Breastfeeding
There is no data available in lactating or nursing women. Preclinical data indicate that small amounts of moxifloxacin are secreted in milk. In the absence of human data and due to the experimental risk of damage by fluoroquinolones to the weight-bearing cartilage of immature animals, breast-feeding is contraindicated during moxifloxacin therapy (see section Contraindications).
Fertility
Animal studies do not indicate impairment of fertility (see section Preclinical safety data).
Interactions with medicinal products
An additive effect on QT interval prolongation of moxifloxacin and other medicinal products that may prolong the QTc interval cannot be excluded. This might lead to an increased risk of ventricular arrhythmias, including torsade de pointes. Therefore, co-administration of moxifloxacin with any of the following medicinal products is contraindicated (see also section Contraindications):
- anti-arrhythmics class IA (e.g. quinidine, hydroquinidine, disopyramide)
- anti-arrhythmics class III (e.g. amiodarone, sotalol, dofetilide, ibutilide)
- antipsychotics (e.g. phenothiazines, pimozide, sertindole, haloperidol, sultopride)
- tricyclic antidepressive agents
- certain antimicrobial agents (saquinavir, sparfloxacin, erythromycin IV, pentamidine, antimalarials particularly halofantrine)
- certain antihistaminics (terfenadine, astemizole, mizolastine)
- others (cisapride, vincamine IV, bepridil, diphemanil).
Moxifloxacin should be used with caution in patients who are taking medication that can reduce potassium levels (e.g. loop and thiazide-type diuretics, laxatives and enemas [high doses], corticosteroids, amphotericin B) or medication that is associated with clinically significant bradycardia.
An interval of about 6 hours should be left between administration of agents containing bivalent or trivalent cations (e.g. antacids containing magnesium or aluminium, didanosine tablets, sucralfate and agents containing iron or zinc) and administration of moxifloxacin.
Concomitant administration of charcoal with an oral dose of 400 mg moxifloxacin led to a pronounced prevention of drug absorption and a reduced systemic availability of the drug by more than 80%. Therefore, the concomitant use of these two drugs is not recommended (except for overdose cases, see also section Overdose).
After repeated dosing in healthy volunteers, moxifloxacin increased Cmax of digoxin by approximately 30% without affecting AUC or trough levels. No precaution is required for use with digoxin.
In studies conducted in diabetic volunteers, concomitant administration of oral moxifloxacin with glibenclamide resulted in a decrease of approximately 21% in the peak plasma concentrations of glibenclamide. The combination of glibenclamide and moxifloxacin could theoretically result in a mild and transient hyperglycaemia. However, the observed pharmacokinetic changes for glibenclamide did not result in changes of the pharmacodynamic parameters (blood glucose, insulin). Therefore no clinically relevant interaction was observed between moxifloxacin and glibenclamide.
Changes in INR
A large number of cases showing an increase in oral anticoagulant activity have been reported in patients receiving antibacterial agents, especially fluoroquinolones, macrolides, tetracyclines, cotrimoxazole and some cephalosporins. The infectious and inflammatory conditions, age and general status of the patient appear to be risk factors. Under these circumstances, it is difficult to evaluate whether the infection or the treatment caused the INR (international normalised ratio) disorder. A precautionary measure would be to more frequently monitor the INR. If necessary, the oral anticoagulant dosage should be adjusted as appropriate.
Clinical studies have shown no interactions following concomitant administration of moxifloxacin with: ranitidine, probenecid, oral contraceptives, calcium supplements, morphine administered parenterally, theophylline, cyclosporine or itraconazole.
In vitro studies with human cytochrome P450 enzymes support these findings. Considering these results a metabolic interaction via cytochrome P450 enzymes is unlikely.
Interaction with food
Moxifloxacin has no clinically relevant interaction with food including dairy products.
Adverse reactions based on all clinical trials and derived from post-marketing reports with moxifloxacin 400 mg (oral and sequential therapy) sorted by frequencies are listed below.
Apart from nausea and diarrhoea all adverse reactions were observed at frequencies below 3%.
Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness. Frequencies are defined as:
- 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: frequency cannot be estimated from the available data
Infections and infestations
Common: Superinfections due to resistant bacteria or fungi e.g. oral and vaginal candidiasis
Blood and lymphatic system disorders
Uncommon: Anaemia, leucopenia(s), neutropenia, thrombocytopenia, thrombocythemia, blood eosinophilia, prothrombin time prolonged/INR increased.
Very rare: Prothrombin level increased/INR decreased, agranulocytosis, pancytopenia
Immune System Disorders
Uncommon: Allergic reaction (see section Special warnings and precautions for use)
Rare: Anaphylaxis incl. very rarely life-threatening shock (see section Special warnings and precautions for use), allergic oedema / angioedema (incl. laryngeal oedema, potentially life-threatening, see section Special warnings and precautions for use)
Endocrine disorders
Very rare: Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Metabolism and nutrition disorders
Uncommon: Hyperlipidemia
Rare: Hyperglycemia, hyperuricemia
Very rare: Hypoglycemia, hypoglycaemic coma
Psychiatric disorders*
Uncommon: Anxiety reactions, psychomotor hyperactivity/agitation
Rare: Emotional lability, depression (in very rare cases potentially culminating in self-injurious behaviour, such as suicidal ideations/ thoughts, or suicide attempts, see section Special warnings and precautions for use), hallucination, delirium
Very rare: Depersonalization, psychotic reactions (potentially culminating in self-injurious behaviour, such as suicidal ideations/ thoughts, or suicide attempts, see section Special warnings and precautions for use)
Nervous system disorders*
Common: Headache, dizziness
Uncommon: Par- and dysaesthesia, taste disorders (incl. ageusia in very rare cases), confusion and disorientation, sleep disorders (predominantly insomnia), tremor, vertigo, somnolence
Rare: Hypoaesthesia, smell disorders (incl. anosmia), abnormal dreams, disturbed coordination (incl. gait disturbances, esp. due to dizziness or vertigo), seizures incl. grand mal convulsions (see section Special warnings and precautions for use), disturbed attention, speech disorders, amnesia, peripheral neuropathy and polyneuropathy
Very rare: Hyperaesthesia
Eye disorders*
Uncommon: Visual disturbances incl. diplopia and blurred vision (especially in the course of CNS reactions, see section Special warnings and precautions for use)
Rare: Photophobia
Very rare: Transient loss of vision (especially in the course of CNS reactions, see sections Special warnings and precautions for use; Effects on ability to drive and use machines), uveitis and bilateral acute iris transillumination (see section Special warnings and precautions for use)
Ear and labyrinth disorders*
Rare: Tinnitus, hearing impairment incl. deafness (usually reversible)
Cardiac disorders**
Common: QT prolongation in patients with hypokalaemia (see sections Contraindications and Special warnings and precautions for use)
Uncommon: QT prolongation (see section Special warnings and precautions for use), palpitations, tachycardia, atrial fibrillation, angina pectoris
Rare: Ventricular tachyarrhythmias, syncope (i.e., acute and short lasting loss of consciousness)
Very rare: Unspecified Arrhythmias, torsade de Pointes (see section Special warnings and precautions for use), cardiac arrest (see section Special warnings and precautions for use)
Vascular disorders**
Uncommon: Vasodilatation
Rare: Hypertension, hypotension
Very rare: Vasculitis
Respiratory, thoracic and mediastinal disorders
Uncommon: Dyspnea (including asthmatic conditions)
Gastrointestinal disorders
Common: Nausea, vomiting, gastrointestinal and abdominal pains, diarrhoea
Uncommon: Decreased appetite and food intake, constipation, dyspepsia, flatulence, gastritis, increased amylase
Rare: Dysphagia, stomatitis, antibiotic associated colitis (incl. pseudomembranous colitis, in very rare cases associated with life-threatening complications, see section Special warnings and precautions for use)
Hepatobiliary disorders
Common: Increase in transaminases
Uncommon: Hepatic impairment (incl. LDH increase), increased bilirubin, increased gamma-glutamyl- transferase, increase in blood alkaline phosphatase
Rare: Jaundice, Hepatitis (predominantly cholestatic)
Very rare: Fulminant hepatitis potentially leading to life-threatening liver failure (incl. fatal cases, see section Special warnings and precautions for use)
Skin and subcutaneous tissue disorders
Uncommon: Pruritus, rash, urticaria, dry skin
Very rare: Bullous skin reactions like Stevens-Johnson syndrome or toxic epidermal necrolysis (potentially life-threatening, see section Special warnings and precautions for use)
Not known: Acute Generalised Exanthematous Pustulosis (AGEP)
Musculoskeletal, connective tissue and bone disorders*
Uncommon: Arthralgia, myalgia
Rare: Tendonitis (see section Special warnings and precautions for use), muscle cramp, muscle twitching, muscle weakness
Very rare: Tendon rupture (see section Special warnings and precautions for use), arthritis, muscle rigidity, exacerbation of symptoms of myasthenia gravis (see section Special warnings and precautions for use)
Not known: Rhabdomyolysis
Renal and urinary disorders
Uncommon: Dehydration
Rare: Renal impairment (incl. increase in BUN and creatinine, see section Special warnings and precautions for use).
General disorders and administration site conditions*
Uncommon: Feeling unwell (predominantly asthenia or fatigue), painful conditions (incl. pain in back, chest, pelvic and extremities), sweating
Rare: Oedema
There have been very rare cases of the following side effects reported following treatment with other fluoroquinolones, which might possibly also occur during treatment with moxifloxacin: increased intracranial pressure (including pseudotumor cerebri), hypernatraemia, hypercalcaemia, haemolytic anaemia, photosensitivity reactions (see section Special warnings and precautions for use).
*Very rare cases of prolonged (up to months or years), disabling and potentially irreversible serious drug reactions affecting several, sometimes multiple, system organ classes and senses (including reactions such as tendonitis, tendon rupture, arthralgia, pain in extremities, gait disturbance, neuropathies associated with paraesthesia, depression, fatigue, memory impairment, sleep disorders, and impairment of hearing, vision, taste and smell) have been reported in association with the use of quinolones and fluoroquinolones in some cases irrespective of pre-existing risk factors (see Section Special warnings and precautions for use).
** Cases of aortic aneurysm and dissection, sometimes complicated by rupture (including fatal ones), and of regurgitation/incompetence of any of the heart valves have been reported in patients receiving fluoroquinolones (see section Special warnings and precautions for use).
Please inform your doctor of all undesirable effects upon drug administration.
No specific countermeasures after accidental overdose are recommended. In the event of overdose, symptomatic treatment should be implemented. ECG monitoring should be undertaken, because of the possibility of QT interval prolongation. Concomitant administration of charcoal with a dose of 400 mg oral moxifloxacin will reduce systemic availability of the drug by more than 80%. The use of charcoal early during absorption may be useful to prevent excessive increase in the systemic exposure to moxifloxacin in cases of oral overdose.
Store in dry places, not exceeding 30oC, protect from light.
Moxifloxacin is indicated for the treatment of the following bacterial infections in patients of 18 years and older caused by bacteria susceptible to moxifloxacin (see sections Special warnings and precautions for use, Undesirable effects, and Pharmacodynamic properties).
- Community acquired pneumonia, except severe cases.
- Mild to moderate pelvic inflammatory disease (i.e. infections of female upper genital tract, including salpingitis and endometritis), without an associated tubo-ovarian or pelvic abscess.
Moxifloxacin is not recommended for use in monotherapy of mild to moderate pelvic inflammatory disease but should be given in combination with another appropriate antibacterial agent (e.g. a cephalosporin) due to increasing moxifloxacin resistance of Neisseria gonorrhoeae unless moxifloxacin-resistant Neisseria gonorrhoeae can be excluded (see sections Special warnings and precautions for use and Pharmacodynamic properties).
Moxifloxacin may also be used to complete a course of therapy in patients who have shown improvement during initial treatment with intravenous moxifloxacin for the following indications:
- Community acquired pneumonia.
- Complicated skin and skin structure infections.
Moxifloxacin should not be used to initiate therapy for any type of skin and skin structure infection or in severe community-acquired pneumonia.
Moxifloxacin should be used only when it is considered inappropriate to use antibacterial agents that are commonly recommended for the initial treatment of these infections:
- Acute exacerbations of chronic bronchitis. Because fluoroquinolones, including moxifloxacin, have been associated with serious adverse reactions (see section Special warnings and precautions for use) and for some patients with acute exacerbations of chronic bronchitis is self-limiting, reserve moxifloxacin for treatment of acute exacerbations of chronic bronchitis in patients who have no alternative treatment options.
- Acute bacterial sinusitis. Because fluoroquinolones, including moxifloxacin, have been associated with serious adverse reactions (see section Special warnings and precautions for use) and for some patients with acute bacterial sinusitis is self-limiting, reserve moxifloxacin for treatment of acute bacterial sinusitis in patients who have no alternative treatment options.
Consideration should be given to official guidance on the appropriate use of antibacterial agents.
- Hypersensitivity to moxifloxacin, other quinolones or to any of the excipients listed in section Excipients.
- Pregnancy and lactation (see section Use in pregnancy and lactation).
- Patients below 18 years of age.
- Patients with a history of tendon disease/disorder related to quinolone treatment.
Both in preclinical investigations and in humans, changes in cardiac electrophysiology have been observed following exposure to moxifloxacin, in the form of QT prolongation. For reasons of drug safety, moxifloxacin is therefore contraindicated in patients with:
- Congenital or documented acquired QT prolongation.
- Electrolyte disturbances, particularly in uncorrected hypokalaemia.
- Clinically relevant bradycardia.
- Clinically relevant heart failure with reduced left-ventricular ejection fraction.
- Previous history of symptomatic arrhythmias.
Moxifloxacin should not be used concurrently with other drugs that prolong the QT interval (see also section Interactions).
Due to limited clinical data, moxifloxacin is also contraindicated in patients with impaired liver function (Child Pugh C) and in patients with transaminases increase > 5 fold ULN.
METHOD OF ADMINISTRATION
For oral administration.
The film-coated tablet should be swallowed whole with sufficient liquid and may be taken independent of meals.
POSOLOGY
Adults
The recommended dose is 400 mg (1 tablet) once daily.
Renal/hepatic impairment
No adjustment of dosage is required in patients with mild to severely impaired renal function or in patients on chronic dialysis i.e. haemodialysis and continuous ambulatory peritoneal dialysis (see section Pharmacodynamic properties for more details).
There is insufficient data in patients with impaired liver function (see section Contraindications).
Other special populations
No adjustment of dosage is required in the elderly and in patients with low bodyweight.
Paediatric population
Moxifloxacin is contraindicated in children and adolescents (< 18 years). Efficacy and safety of moxifloxacin in children and adolescents have not been established (see section Contraindications).
Duration of administration
Moxifloxacin should be used for the following treatment durations:
- Community acquired pneumonia: 10 days
- Mild to moderate pelvic inflammatory disease: 14 days
- Acute exacerbation of chronic obstructive pulmonary disease including bronchitis: 5 - 10 days
- Acute bacterial sinusitis: 7 days
Moxifloxacin have been studied in clinical trials for up to 14 days of treatment.
Sequential (intravenous followed by oral) therapy
In clinical studies with sequential therapy most patients switched from intravenous to oral therapy within 4 days (community-acquired pneumonia) or 6 days (complicated skin and skin structure infections). The recommended total duration of intravenous and oral treatment is 7 - 14 days for community-acquired pneumonia and 7 - 21 days for complicated skin and skin structure infections.
The recommended dose (400 mg per day) and duration of therapy for the indication being treated should not be exceeded.
Or as directed by the physician.
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