Drug Class Description
Nitroimidazoles.

Generic Name
Metronidazole - anaerobic infections

Drug Description
Each 5ml of suspension contains 200mg metronidazole (as the benzoate)ExcipientsThis medicinal product contains small amounts of ethanol (alcohol), less than 100mg per 5ml

Presentation
Oral suspensionFlagyl S suspension is a white to cream suspension with a slight yellow tinge and an odour of orange and lemon

Indications
Flagyl S is administered orally for:1. The prevention of post-operative infections due to anaerobic bacteria, particularly species of Bacteroides, and anaerobic streptococci.2. Treatment of urogenital trichomonas in the female (trichomonal vaginitis) and in the male.3. Treatment of all forms of amoebiasis (intestinal and extra-intestinal disease and that of symptomless cyst passers).4. Treatment of giardiasis.5. Treatment of acute ulcerative gingivitis (Vincent's).6. Treatment of anaerobically-infected leg ulcers and pressure sores.7. Treatment of acute dental infections (e.g. acute pericoronitis and acute apical infections).8. Treatment of septicaemia, bacteraemia, brain abscess, necrotising pneumonia, osteomyelitis, puerperal sepsis, pelvic abscess, pelvic cellulitis, peritonitis, and post-operative wound infections from which pathogenic anaerobes have been isolated.9. Non specific vaginitis.

Adult Dosage
For oral administration.Suspension can be diluted with syrup BP.Dosage is given in terms of metronidazole or metronidazole equivalent.Treatment of anaerobic infections:Treatment for seven days should be satisfactory for most patients but, depending on the clinical and bacteriological assessments, the physician might decide to prolong treatment. The tablets or suspension may be given alone or concurrently with other appropriate antibacterial agents.Adults and children over 10 years - 400 mg orally three times daily.Children and infants - 7.5 mg/kg bodyweight three times daily.Protozoal and other infections:Dosage is given in terms of metronidazole or metronidazole equivalentDuration of dosage in daysAdults and children over 10 yearsChildren7 to 10 years3 to 7 years1 to 3 yearsUrogenital trichomoniasisWhere re-infection is likely, in adults the consort should receive a similar course of treatment concurrently7or2or 200 mg three times daily800 mg in the morning and 1,200 mg in the evening2.0 g as a single dose 100 mg three times daily100 mg twice daily50 mg three times dailyNon-specific vaginitis7or1 400 mg twice daily2.0g as a single dose Dosage is given in terms of metronidazole or metronidazole equivalentDuration of dosage in daysAdults and children over 10 yearsChildren7 to 10 years3 to 7 years1 to 3 yearsAmoebiasis(a) Invasive intestinal disease in susceptible subjects5800 mg three times daily400 mg three times daily200 mg four times daily200 mg three times daily(b) Intestinal disease in less susceptible subjects and chronic amoebic hepatitis(c) Amoebic liver abscess also other forms of extra-intestinal amoebiasis5-105400 mg three times daily200 mg three times daily100 mg four times daily100 mg three times daily(d) Symptomless cyst passers5-10400-800 mg three times daily200-400 mg three times daily100-200 mg four times daily100-200 mg three times dailyGiardiasis32.0 g once daily1.0 g once daily600-800 mg once daily500 mg once dailyAcute ulcerative gingivitis3200 mg three times daily100 mg three times daily100 mg twice daily50 mg three times dailyAcute dental infections3-7200 mg three times dailyLeg ulcers and pressure sores7400 mg three times dailyImmature children and infants weighing less than 10 kg should receive proportionally smaller dosages.

Child Dosage
Flagyl Tablets and Flagyl-S Suspension: 7 .5 mg/kg three times daily. Flagyl Suppositories: 7.5 mg/kg rectally eight hourly for three days, then oral therapy.

Contra Indications
Known hypersensitivity to metronidazole or any of the excipients.

Special Precautions
Flagyl suspension contains methylhydroxybenzoate and propylhydroxybenzoate which may cause allergic reactions (possibly delayed).Flagyl suspension contains small amounts of ethanol (alcohol), less than 100mg per 5ml.Regular clinical and laboratory monitoring are advised if administration of Flagyl for more than 10 days is considered to be necessary.There is a possibility that after Trichomonas vaginalis has been eliminated a gonococcal infection might persist.The elimination half-life of metronidazole remains unchanged in the presence of renal failure. The dosage of metronidazole therefore needs no reduction. Such patients however retain the metabolites of metronidazole. The clinical significance of this is not known at present.In patients undergoing haemodialysis metronidazole and metabolites are efficiently removed during an eight hour period of dialysis. Metronidazole should therefore be re-administered immediately after haemodialysis.No routine adjustment in the dosage of Flagyl need be made in patients with renal failure undergoing intermittent peritoneal dialysis (IDP) or continuous ambulatory peritoneal dialysis (CAPD).Metronidazole is mainly metabolised by hepatic oxidation. Substantial impairment of metronidazole clearance may occur in the presence of advanced hepatic insufficiency. Significant cumulation may occur in patients with hepatic encephalopathy and the resulting high plasma concentrations of metronidazole may contribute to the symptoms of the encephalopathy. Flagyl should therefore, be administered with caution to patients with hepatic encephalopathy. The daily dosage should be reduced to one third and may be administered once daily.Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take this medicine.

Interactions
Patients should be advised not to take alcohol during metronidazole therapy and for at least 48 hours afterwards because of the possibility of a disulfiram-like (antabuse effect) reaction.Some potentiation of anticoagulant therapy has been reported when metronidazole has been used with the warfarin type oral anticoagulants. Dosage of the latter may require reducing. Prothrombin times should be monitored. There is no interaction with heparin.Lithium retention accompanied by evidence of possible renal damage has been reported in patients treated simultaneously with lithium and metronidazole. Lithium treatment should be tapered or withdrawn before administering metronidazole. Plasma concentrations of lithium, creatinine and electrolytes should be monitored in patients under treatment with lithium while they receive metronidazole.Patients receiving phenobarbital metabolise metronidazole at a much greater rate than normally, reducing the half-life to approximately 3 hours.Metronidazole reduces the clearance of 5 fluorouracil and can therefore result in increased toxicity of 5 fluorouracil.Patients receiving ciclosporin are at risk of elevated ciclosporin serum levels. Serum ciclosporin and serum creatinine should be closely monitored when coadministration is necessary.Plasma levels of busulfan may be increased by metronidazole which may lead to severe busulfan toxicity.

Adverse Reactions
The frequency of adverse events listed below is defined using the following convention: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).Serious adverse reactions occur rarely with standard recommended regimens. Clinicians who contemplate continuous therapy for the relief of chronic conditions, for periods longer than those recommended, are advised to consider the possible therapeutic benefit against the risk of peripheral neuropathy.Blood and lymphatic system disorders:Very rare: agranulocytosis, neutropenia, thrombocytopenia, pancytopeniaNot known: leucopenia.Immune system disorders:Rare: anaphylaxisNot known: angiodema, urticaria, fever.Metabolism and nutrition disorders:Not known: anorexia.Psychiatric disorders:Very rare: psychotic disorders, including confusion and hallucinations.Not known: depressed moodNervous system disorders:Very rare:• encephalopathy (eg. confusion, fever, headache, hallucinations, paralysis, light sensitivity, disturbances in sight and movement, stiff neck) and subacute cerebellar syndrome (eg. ataxia, dysathria, gait impairment, nystagmus and tremor) which may resolve on discontinuation of the drug.• drowsiness, dizziness, convulsions, headachesNot known:• during intensive and/or prolonged metronidazole therapy, peripheral sensory neuropathy or transient epileptiform seizures have been reported. In most cases neuropathy disappeared after treatment was stopped or when dosage was reduced.• aseptic meningitisEye disorders:Very rare: vision disorders such as diplopia and myopia, which, in most cases, is transient.Not Known: optic neuropathy/neuritisGastrointestinal disorders:Not known: taste disorders, oral mucositis, furred tongue, nausea, vomiting, gastro-intestinal disturbances such as epigastric pain and diarrhoea.Hepatobiliary disorders:Very rare: abnormal liver function tests, cholestatic hepatitis, jaundice and pancreatitis which is reversible on drug withdrawal.Skin and subcutaneous tissue disorders:Very rare: skin rashes, pustular eruptions, pruritis, flushingNot known: erythema multiforme.Musculoskeletal, connective tissue and bone disorders:Very rare: myalgia, arthralgia.Renal and urinary disorders:Very rare: darkening of urine (due to metronidazole metabolite).

Manufacturer
Winthrop Pharmaceuticals UK Ltd

Drug Availability
(POM)

Updated
23 November 2011