Clodronate disodium and lidocaine hydrochloride Pharmeg: detailed information

Patient Information Leaflet

CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG 200 mg + 40 mg

Injectable solution
Clodronate disodium – lidocaine hydrochloride
Generic medicine
Read this leaflet carefully before using this medicine because it contains important information for you.

Keep this leaflet. You may need to read it again.
If you have any questions, ask your doctor or pharmacist.
This medicine has been prescribed for you only. Do not give it to others, even if their symptoms are the same as yours, as it could be harmful.
If you experience any adverse reaction, including those not listed in this leaflet, contact your doctor or pharmacist. See section 4.

Contents of this leaflet:

What CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG is and what it is used for
What you need to know before using CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG
How to use CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG
Possible side effects
How to store CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG
Package contents and other information

1. What CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG is and what it is used for
CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG is a medicine that contains clodronic acid, an active substance belonging to a group of drugs used in the treatment of bone diseases called bisphosphonates.
CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG is used in women for the prevention and treatment of bone thinning (osteoporosis) after menopause (the period of permanent cessation of menstrual cycles).

2. What you need to know before using CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE

PHARMEG
Do not use CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG:

If you are allergic to clodronic acid or to any of the other ingredients of this medicine (listed in section 6).
If you are taking other bisphosphonates, medicines similar to CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG.
If you are allergic to lidocaine or to other amide-type local anesthetics, such as: bupivacaine, mepivacaine, ropivacaine, levobupivacaine.
If you have a heart condition causing loss of consciousness (Adam-Stokes syndrome).
If you have a heart rhythm disorder (Wolff-Parkinson-White syndrome, atrial fibrillation, sinoatrial, atrioventricular or intraventricular block).
If you have weak heart function unable to supply adequate blood flow to the body (acute heart failure).
If you have a condition characterized by reduced blood volume (hypovolemia).

This medicine is for intramuscular use only (i.e. to be injected into a muscle) and must not be administered into a blood vessel (intravenously). Accidental injection into a vein increases the risk of serious adverse reactions due to high blood levels of the anesthetic lidocaine (see section 3. If you use more CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG than you should).

Warnings and precautions
Talk to your doctor or pharmacist before using CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG.
Before and during treatment, your doctor will ask you to undergo blood tests to monitor kidney and liver function (see section 4. Possible side effects). It is important that you drink an adequate amount of fluids during treatment with this medicine, especially if you have kidney problems (see section 3. How to use CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG).

In particular, inform your doctor if:

You have high levels of calcium in your blood.
You have a kidney disease (renal insufficiency).
You are being treated with CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG for cancer or osteoporosis and are undergoing dental treatment or are scheduled for dental surgery. You should also inform your dentist that you are being treated with CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG (see section 4. Possible side effects), as preventive dental treatment may be necessary.
You have heart diseases (particularly heart rhythm disorders with slow heart rate or heart failure) or have had heart surgery.
You have a liver disease.
You or someone in your family has a condition causing a marked increase in body temperature following the use of local anesthetics such as lidocaine (malignant familial hyperthermia).
You experience thigh, hip or groin pain or weakness during treatment, as this may be an early sign of a possible femoral fracture (see section 4. Possible side effects).
You have seizures (epilepsy). Your doctor will closely monitor you for any symptoms.
You have respiratory or lung disorders.
You have a disease causing muscle weakness (myasthenia gravis).
You have porphyria (a rare inherited blood cell disorder affecting the skin and nervous system).

Children and adolescents
The safety and efficacy of this medicine in pediatric patients have not been established.

Other medicines and CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG
Inform your doctor or pharmacist if you are taking, have recently taken or might take any other medicines.
This is particularly important if:

You are taking other bisphosphonates, medicines used to treat bone diseases, as concomitant use of CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG with other bisphosphonates is contraindicated (see section 2. Do not use CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG).
You are taking non-steroidal anti-inflammatory drugs (NSAIDs), medicines used to treat inflammation (particularly diclofenac), as kidney problems may occur.
You are taking aminoglycosides, medicines used to treat infections, as blood calcium levels may decrease (hypocalcemia).
You are taking estramustine, a medicine used to treat prostate cancer (a gland in men that produces seminal fluid), as blood levels of estramustine may increase.
You are taking medicines used to treat heart conditions, including irregular heartbeat, such as beta-blockers (e.g. propranolol), calcium channel blockers (e.g. amiodarone) or sodium channel blockers, as lidocaine may remain in circulation longer.
You are taking cimetidine, a medicine mainly used to treat gastritis and gastric ulcer (a lesion of the stomach wall); fluvoxamine (a medicine used for depression); antiviral medicines such as ritonavir; antibiotics such as macrolides (erythromycin) or other antibiotics like ciprofloxacin; antifungal medicines such as ketoconazole, itraconazole, as blood levels of lidocaine may increase.
You are taking barbiturates such as phenobarbital; medicines used to treat epilepsy such as carbamazepine; phenytoin; primidone; oral contraceptives or hormone replacement therapy, as blood levels of lidocaine may decrease.
You are being treated with digitalis, medicines used to treat heart rhythm disorders, as this may increase the risk of heart rhythm disturbances.
You are taking muscle relaxants used during general anesthesia, such as suxamethonium.

The solution is incompatible with alkaline solutions or oxidizing solutions.

Pregnancy, breastfeeding and fertility
If you are pregnant, think you may be pregnant or are planning to become pregnant, or if you are breastfeeding, consult your doctor or pharmacist before using this medicine.

Pregnancy
Avoid using CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG during pregnancy and if you are of childbearing age and not using an effective contraceptive method (medicines used to prevent pregnancy).

Breastfeeding
It is not known whether clodronic acid passes into breast milk, while lidocaine is excreted in breast milk in small amounts. Therefore, during treatment with CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG, breastfeeding should be discontinued.

Fertility
It is not known whether clodronic acid and lidocaine have effects on human fertility.

Driving and using machines
CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG may cause visual disturbances that could affect your ability to drive or operate machinery.
If you experience one or more of the symptoms listed in section 4 or if you use more CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG than you should, avoid driving and using machinery.

CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG contains sodium
This medicine contains 32 mg of sodium (the main component of table salt) per dose.
This corresponds to 1.6% of the maximum recommended daily dietary intake for an adult.

3. How to use CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG

Use this medicine exactly as directed by your doctor, who will determine the correct dose for you based on the severity of your condition, as well as the duration of treatment. If you have any doubts, consult your doctor or pharmacist (see the section DOSAGE, METHOD AND DURATION OF ADMINISTRATION at the end of this Patient Information Leaflet).

Clodronic acid is primarily eliminated via the kidneys. Therefore, during treatment with clodronic acid, it is necessary to maintain adequate fluid intake.

Method of administration
CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG is for intramuscular use only (i.e. to be injected into a muscle). To avoid accidental injection into a blood vessel, it is recommended to aspirate before injecting the medicine.

Avoid massaging the injection site.

If you use more CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG than you should
In case of accidental overdose of CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG, seek immediate medical attention from your doctor or go to the nearest hospital.

Symptoms of overdose may include:

increased blood creatinine levels and kidney disease (renal dysfunction) (with high doses of clodronic acid administered intravenously),
elevated blood nitrogen levels (uremia),
liver damage,
low levels of calcium in the blood (hypocalcemia).

In case of accidental intravascular injection, the following symptoms of lidocaine overdose may occur:

drowsiness,
euphoria (state of excessive excitement),
sedation (physical and mental relaxation),
loss of sensation in certain parts of the body (paraesthesias),
muscle spasms (sudden, involuntary muscle contractions),
uncontrolled body movements (convulsions),
reduced blood flow to the body (cardiocirculatory collapse).

Treatment
Your doctor will manage the symptoms with specific therapies.

If you forget to use CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG
Do not take a double dose to make up for the missed dose.

If you stop treatment with CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG
If you have any doubts about using this medicine, consult your doctor or pharmacist.

4. Possible side effects

Like all medicines, this medicine can cause side effects, although not everybody gets them.
If you experience any eye or vision problems during treatment, STOP taking the medicine and consult an ophthalmologist.
Immediately inform your doctor if you experience:

pain or sores in the mouth or jaw and/or maxilla (two facial bones), as these may be early signs of serious problems (bone death of the jaw and/or maxilla), usually associated with tooth extraction and/or local infection (see section 2. Warnings and precautions).

The possible side effects listed below are categorized by frequency:
Common (may affect up to 1 in 10 people):

decreased levels of calcium in the blood, without symptoms (asymptomatic hypocalcaemia),
diarrhoea, nausea, vomiting (usually mild in severity),
increased levels of transaminases in the blood (a test to assess liver function), usually within normal limits.

Uncommon (may affect up to 1 in 1,000 people):

decreased levels of calcium in the blood, with symptoms (symptomatic hypocalcaemia),
increased levels of parathyroid hormone (a hormone that regulates calcium levels) in the blood, associated with low blood calcium,
increased levels of alkaline phosphatase in the blood (a test to assess bone and liver condition),
increased levels of transaminases in the blood (a test to assess liver function) more than twice the upper normal limit, without other abnormalities in liver function,
allergic reactions manifesting as skin reactions,
unusual femur fracture (thigh bone), particularly in patients receiving long-term treatment for osteoporosis. Contact your doctor if you experience pain or weakness in the thigh, hip, or groin, as this could be an early sign of a possible femur fracture.

Rare (may affect up to 1 in 10,000 people):

consult your doctor if you experience ear pain, ear discharge, and/or ear infection. These events could be signs of bone damage in the ear.

The following side effects may also occur, for which the frequency cannot be determined from the available data:
Effects related to the eyes

inflammation of the conjunctiva, the membrane covering the eye and inner eyelids (conjunctivitis);
eye inflammation (episcleritis, scleritis, and uveitis).
Episcleritis and scleritis have been reported with other drugs in the same class as clodronic acid (adverse class reaction of bisphosphonates).

Effects related to the lungs

breathing difficulties in patients with aspirin-sensitive asthma (a medicine used to treat fever, pain, and inflammation);
allergic reactions manifesting as respiratory problems.

Effects related to the kidneys and urinary tract

kidney disease (renal failure), severe kidney damage. Rarely, and especially in association with NSAIDs (medicines used to treat inflammation and pain), renal failure has led to death (more frequently with concomitant use of diclofenac). See section 2. Other medicines and CLODRONATO DISODICO E LIDOCAINA CLORIDRATO PHARMEG.

Effects related to bones and muscles

severe bone, joint, and muscle pain. The onset of symptoms varies from days to several months after starting treatment with CLODRONATO DISODICO E LIDOCAINA CLORIDRATO PHARMEG;
pain or sores in the mouth or jaw and/or maxilla (two facial bones). These may be early signs of serious problems (bone death of the jaw and/or maxilla), usually associated with tooth extraction and/or local infection (see section 2. Warnings and precautions). In most cases, this has occurred in patients with cancer.

Effects related to the injection site

tenderness at the injection site, particularly considering the duration of treatment.

Side effects specific to lidocaine
The following side effects are associated with lidocaine; however, there are insufficient data to determine the frequency of the individual effects listed. Side effects are generally due to either allergic reactions or excessively high blood concentrations resulting from accidental intravascular injection and/or overdose.
This may occasionally cause central nervous system excitation and occasional cardiovascular depression (see section 2. Warnings and precautions).
Immune system disorders
Severe allergic reaction (anaphylactoid), swelling of the larynx leading to breathing difficulty (bronchospasm), and drop in blood pressure (cardiorespiratory collapse) due to anaphylactic shock.
Nervous system disorders
Signs of excitation or depression associated with dizziness, drowsiness, visual disturbances, tremors, followed by changes in consciousness, seizures, coma, prolonged contraction of the jaw muscles leading to tight closure of the jaw and maxilla (trismus), altered sensation in limbs or other body parts (paraesthesia).
Psychiatric disorders
Anxiety, disorientation.
Cardiac disorders
Slowing of the heart rate (bradycardia), changes in heart rhythm (arrhythmias), myocardial depression up to cardiac arrest.
Eye disorders
Pupil dilation (mydriasis), blurred vision, double vision (diplopia).
Gastrointestinal disorders
Nausea, vomiting.
Respiratory, thoracic and mediastinal disorders
Difficulty breathing (dyspnoea), reduced breathing rate (respiratory depression).
Vascular disorders
Low blood pressure (hypotension), high blood pressure (hypertension), interruption of normal blood circulation due to cardiac arrest and reduced blood flow (circulatory collapse).
Skin and subcutaneous tissue disorders
Sudden reddening of the skin (various types of skin rashes), skin rash with itchy raised bumps (urticaria), itching.
Ear and labyrinth disorders
Ringing in the ears (tinnitus), increased sensitivity to relatively quiet sounds (hyperacusis).

Reporting of side effects
If you experience any side effect, including those not listed in this leaflet, talk to your doctor or pharmacist. You may also report side effects directly via the national reporting system at https://www.aifa.gov.it/content/segnalazioni-reazioni-avverse.
By reporting side effects, you can help provide more information on the safety of this medicine.

5. How to store CLODRONATE DISODIUM AND LIDOCAINE HYDROCHLORIDE PHARMEG

Keep this medicine out of the sight and reach of children.
This medicine does not require any special storage conditions.
Do not use this medicine after the expiry date stated on the carton after "Exp". The expiry date refers to the last day of that month.
Do not dispose of any medicine via wastewater or household waste. Ask your pharmacist how to dispose of medicines you no longer use. This will help protect the environment.

6. Package contents and other information

What CLODRONATO DISODICO E LIDOCAINA CLORIDRATO PHARMEG contains

The active substances are clodronate disodium (disodium salt of clodronic acid) 200 mg and lidocaine hydrochloride 40 mg.
The other components are sodium hydrogen carbonate (see section 2. CLODRONATO DISODICO E LIDOCAINA CLORIDRATO PHARMEG contains sodium), water for injectable preparations.

Description of the appearance of CLODRONATO DISODICO E LIDOCAINA CLORIDRATO PHARMEG and contents of the pack
Injectable solution, clear and colourless, in packs of 3 - 6 - 9 - 12 vials for intramuscular use.
Marketing Authorization Holder
Pharmeg S.r.l., Via dei Giardini 34, 85033 Episcopia (PZ).
Manufacturer
Biomedica Foscama Industria Chimico-farmaceutica S.p.A. - Via Morolense 87 - 03013 Ferentino (FR)
The following information is intended exclusively for physicians or healthcare professionals:
DOSAGE, METHOD AND DURATION OF ADMINISTRATION
The dosage, depending on the clinical condition and mineralometric values, may vary as follows:
CLODRONATO DISODICO E LIDOCAINA CLORIDRATO PHARMEG every 14-28 days, for 1 year or longer, depending on the patient's condition.
CLODRONATO DISODICO E LIDOCAINA CLORIDRATO PHARMEG can be used in patients who have never previously received treatment with clodronate.
When switching from administration of Clodronate 100 mg + lidocaine 33 mg to CLODRONATO DISODICO E LIDOCAINA CLORIDRATO PHARMEG 200 mg + 40 mg, administration of one vial of CLODRONATO DISODICO E LIDOCAINA CLORIDRATO PHARMEG 200 mg + 40 mg every 14 days may be used as an alternative dosing regimen in patients already being treated with one vial of 100 mg per week.
Administration of one vial of CLODRONATO DISODICO E LIDOCAINA CLORIDRATO PHARMEG 200 mg + 40 mg every 28 days may be used as an alternative dosing regimen in patients already being treated with one vial of 100 mg every two weeks.
The optimal duration of bisphosphonate treatment for osteoporosis has not been established. The need for continued treatment should be periodically reassessed for each individual patient based on potential benefits and risks, particularly after 5 years or more of use.
Special populations
Children
The safety and efficacy of the medicinal product in paediatric patients have not been established.
Elderly
There are no specific dosage recommendations for elderly patients. Clinical studies conducted have included patients aged over 65 years, and no age-specific adverse events have been reported in this age group.
Patients with renal impairment
Clodronate is primarily eliminated via the renal route. Therefore, it should be used with caution in patients with renal impairment. It is recommended to reduce the clodronate dosage as follows:

Renal impairment degree: Creatinine clearance, ml/min	Dosage reduction, %
50-80	25
12-50	25-50
<12	50

Clodronate is recommended to be administered before haemodialysis, with a 50% dose reduction on dialysis-free days, and the treatment regimen should be limited to 5 days. It should be noted that peritoneal dialysis removes clodronate poorly from the circulation.
The solution is incompatible with alkaline solutions or oxidizing solutions.