Clacid - instructions for use, dose, side effects, contraindications

Clarithromycin is a semisynthetic antibiotic in the macrolide group and has an antibacterial effect by interacting with the 50S ribosomal subunit and suppressing protein synthesis of bacteria sensitive to it.

Clarithromycin showed high activity in vitro in relation to both standard laboratory strains of bacteria and those isolated from patients in the course of clinical practice. It shows high activity against many aerobic and anaerobic gram-positive and gram-negative microorganisms. The minimum inhibitory concentrations (MPC) of clarithromycin for most pathogens are smaller than the erythromycin MPC on average by one log₂breeding.

Clarithromycin in vitro highly active in relation to Legionella pneumophila, Mycoplasma pneumoniaeIt has a bactericidal effect against Helicobacter pylori, this activity of clarithromycin is higher at neutral pH than with acid.

In addition, data in vitro and in vivo indicate that clarithromycin acts on clinically significant species of mycobacteria. Enterobacteriaceae and Pseudomonas spp. as well as other non-lactose-fermenting gram-negative bacteria, are not sensitive to clarithromycin.

The activity of clarithromycin against most strains of the microorganisms listed below has been proven in vitro, and in clinical practice for the diseases listed in the section "Indications for use."

Aerobic Gram-positive microorganisms

Staphylococcus aureus

Streptococcus pneumoniae

Streptococcus pyogenes

Listeria monocytogenes

Aerobic Gram-negative microorganisms

Haemophilus influenzae

Haemophilus parainfluenzae

Moraxella catarrhalis

Neisseria gonorrhoeae

Legionella pneumophila

Other microorganisms

Mycoplasma pneumoniae

Chlamydia pneumoniae (TWAR)

Mycobacteria

Mycobacterium leprae

Mycobacterium kansasii

Mycobacterium chelonae

Mycobacterium fortuitum

Mycobacterium avium complex (MAC) - complex, including:

Mycobacterium avium

Mycobacterium intracellulare

The production of beta-lactamase does not affect the activity of clarithromycin. Most strains of staphylococcus aureus resistant to methicillin and oxacillin are resistant to clarithromycin.

Helicobacter pylori

Sensitivity H.pylori to clarithromycin was studied on isolates H.pylori, isolated from 104 patients, before the beginning of drug therapy.In 4 patients, strains resistant to clarithromycin were isolated H.pylori, in 2 cases - strains with moderate resistance, in the remaining 98 patients, isolates H.pylori were sensitive to clarithromycin. Clarithromycin has an effect in vitro and for most strains of the following microorganisms (however, the safety and efficacy of using clarithromycin in clinical practice has not been confirmed by clinical studies and the practical significance remains unclear):

Aerobic Gram-positive microorganisms

Streptococcus agalactiae

Streptococci (groups C, F, G)

Viridans group streptococci

Aerobic Gram-negative microorganisms

Bordetella pertussis

Pasteurella multocida

Anaerobic Gram-positive microorganisms

Clostridim perfringens

Peptococcus niger

Propionibacterium acnes

Anaerobic Gram-negative microorganisms

Bacteroides melaninogenicus

Spirochetes

Borrelia burgdorferi

Treponema pallidum

Campylobacteria

Campylobacter jejuni

The main metabolite of clarithromycin in the human body is the microbiologically active metabolite 14-hydroxyclarithromycin (14-OH-clarithromycin). The microbiological activity of the metabolite is the same as that of the starting material, or 1-2 times weaker in respect of most microorganisms. The exception is H. influenzae, in relation to which the efficiency of the metabolite is twice as high.The starting material and its main metabolite exert either an additive or a synergistic effect on H.influenzae in conditions in vitro and in vivo depending on the strain of bacteria.

Pharmacokinetics:

Distribution, metabolism and excretion

Healthy

In a clinical study involving healthy volunteers clarithromycin was administered intravenously once, at doses of 75, 125, 250 and 500 mg in a volume of 100 ml in the form of infusion for 30 minutes, as well as in doses of 500, 750 or 1000 mg in a volume of 250 ml for more than 60 minutes. The maximum concentrations (C_mOh) of clarithromycin were from 5.16 μg / ml to 9.40 μg / ml after infusion of 500 mg and 1000 mg of clarithromycin for 60 min, respectively. FROM_mOh 14-OH-clarithromycin was 0.66 μg / ml after infusion of 500 mg and 1.06 μg / ml after administration of 1000 mg of clarithromycin for 60 minutes.

In the equilibrium state, the terminal half-life (T_1/2) clarithromycin is dose dependent and ranges from 3.8 hours to 4.5 hours when doses from 500 mg to 1000 mg are administered for 60 minutes, respectively. T1/2 14-OH-clarithromycin showed a dose-related increase with higher doses and was 7.3 hours after administration of 500 mg and 9.3 hours after administration of a dose of 1000 mg for 60 minutes.

The average value of the area under the "concentration-time" curve (AUC) clarithromycin demonstrated a nonlinear dose-dependent increase from 22.29 h * μg / ml after a dose of 500 mg to 53.26 h-μg / ml after a dose of 1000 mg. Average value AUC 14-OH-clarithromycin was from 8.16 h * μg / ml to 14.76 h-μg / ml when the same doses were administered for 60 min.

In a 7-day clinical trial clarithromycin injected multiple times at doses of 125 and 250 mg in a volume of 100 ml for more than 30 minutes, and at doses of 500 and 750 mg in a volume of 250 ml for more than 60 minutes every 12 hours. In this study, the value of C_mOh in the equilibrium state increased from 5.5 μg / ml at a dose of 500 mg to 8.6 μg / ml at a dose of 750 mg. In the equilibrium state T_1/2clarithromycin after infusion for more than 60 min at doses of 500 mg and 750 mg was 5.3 hours and 4.8 hours, respectively. FROM_mOh 14-OH-clarithromycin in the equilibrium state after administration of 500 mg and 750 mg doses increased from 1.02 μg / ml to 1.37 μg / ml, respectively. T1/2 14-OH-clarithromycin in the groups administered 500 mg or 750 mg was 7.9 hours and 5.4 hours, respectively. The pharmacokinetics of 14-OH-clarithromycin did not depend on the dose.

Patients

Clarithromycin and its metabolite 14-OH-clarithromycin rapidly penetrate into tissues and body fluids. Tissue and serum concentrations in the human body are presented in the table.

	Concentration
(after applying 250 mg every 12 hours)
Type of fabric	Cloth (μg / g)	Serum (μg / ml)
Tonsils	1,6	0,8
Lungs	8,8	1,7

Patients with mycobacterial infections

At present, there is no generalized data on intravenous administration of (iv) clarithromycin in mycobacterial infections in adult patients with HIV infection, there are pharmacokinetic data on the use of clarithromycin tablets in these infections. The equilibrium concentration of clarithromycin and 14-OH-clarithromycin after the admission of adult doses of clarithromycin in adults with HIV-infected patients was similar to that of healthy people. However, when using clarithromycin at higher doses, which may be required for the treatment of mycobacterial infections, the concentration of antibiotic can be significantly higher than usual.

When using the drug at higher doses, lengthening T_1/2 compared with that of healthy people who received clarithromycin in usual doses. An increase in plasma concentration and a longer half-life with the appointment of clarithromycin at higher doses are consistent with the known non-linearity of the pharmacokinetics of the drug.

Indications:

Infectious-inflammatory diseases caused by microorganisms sensitive to clarithromycin:

- infections of the lower respiratory tract (such as bronchitis, pneumonia);

- upper respiratory tract infections (such as pharyngitis, sinusitis);

- infections of the skin and soft tissues (such as folliculitis, inflammation of the subcutaneous tissue, erysipelas);

- disseminated or localized mycobacterial infections caused by Mycobacterium avium and Mycobacterium intracellulare;

- localized infections caused by Mycobacterium chelonae, Mycobacterium fortuitum and Mycobacterium kansasii.

Contraindications:

- Hypersensitivity to clarithromycin, other components of the drug and other macrolides;

- concurrent use of clarithromycin with the following drugs: astemizole, cisapride, pimozide, terfenadine (see section "Interaction with other medicinal products");

- simultaneous application of clarithromycin with ergot alkaloids, for example, ergotamine, dihydroergotamine (see section "Interaction with other medicinal products");

- simultaneous use of clarithromycin with midazolam for oral administration (see section "Interaction with other medicinal products").

- simultaneous use of clarithromycin with HMG-CoA reductase inhibitors (statins), which are largely metabolized by isoenzyme CYP3A4 (lovastatin, simvastatin), due to the increased risk of myopathy, including rhabdomyolysis (see "Interaction with Other Drugs");

- simultaneous use of clarithromycin with colchicine;

- simultaneous application of clarithromycin with ticagrelor or ranolazine;

- interval lengthening QT in the anamnesis, ventricular arrhythmia or ventricular tachycardia of the "pirouette" type;

- hypokalemia (risk of lengthening the interval QT);

- severe hepatic insufficiency, which occurs simultaneously with renal insufficiency;

- Cholestatic jaundice / hepatitis in history, developed with the use of clarithromycin (see section "Special instructions");

- PThe period of breastfeeding;

- age to 18 years (efficacy and safety not established).

Carefully:

- Renal failure of moderate to severe severity;

- hepatic insufficiency of moderate and severe degree;

- simultaneous reception of clarithromycin with benzodiazepines, such as alprazolam, triazolam, midazolam for intravenous use (see "Interaction with other medicinal products");

- simultaneous reception of clarithromycin with other ototoxic drugs, especially aminoglycosides (see section "Interaction with other medicinal products");

- simultaneous reception with drugs that are metabolized by the isoenzyme CYP3A, for example, carbamazepine, cilostazol, ciclosporin, disopyramide, methylprednisolone, omeprazole, indirect anticoagulants (for example, warfarin), quinidine, rifabutin, sildenafil, tacrolimus, vinblastine (see the section "Interaction with other medicinal products");

- simultaneous administration with drugs inducing isoenzyme CYP3A4, for example, rifampicin, phenytoin, carbamazepine, phenobarbital, St John's wort (see "Interaction with other medicinal products");

- simultaneous reception of clarithromycin with statins that do not depend on the metabolism of the isoenzyme CYP3A (for example, fluvastatin) (see the section "Interaction with other medicinal products");

- simultaneous reception with blockers of "slow" calcium channels, which are metabolized by the isoenzyme CYP3A4 (for example, verapamil, amlodipine, diltiazem);

- Patients with coronary heart disease (CHD), severe heart failure, hypomagnesemia, severe bradycardia (less than 50 beats per minute), and patients taking antiarrhythmic drugs of the IA class simultaneously (quinidine, procainamide) and III class (dofetilide, amiodarone, sotalol);

- Pregnancy.

Pregnancy and lactation:

The safety of the use of clarithromycin during pregnancy and during breastfeeding has not been established.

The use of clarithromycin in pregnancy (especially in the first trimester) is possible only if there is no alternative therapy, and the potential benefit to the mother exceeds the potential risk to the fetus.

Clarithromycin is excreted in breast milk. If you need to take during lactation, breastfeeding should be stopped.

Dosing and Administration:

For intravenous infusion.

Intramuscular and bolus administration is forbidden!

The recommended dose of clarithromycin IV is 1.0 g / day, divided into two equal doses, each of which is administered after dissolution in an appropriate solvent drip during 60 min and more.

Patients with mycobacterial infections

Data on the use of clarithromycin in / in patients with impaired immunity are absent. In HIV-infected patients clarithromycin was applied inside. Patients with localized and disseminated mycobacterial infections caused by M. avium, M.Intracellulare, M.chelonae, M.fortuitum, M. kansasii, the recommended dose of clarithromycin for adults is 1.0 g per day, divided into two equal doses.

Intravenous therapy in severe patients can be limited to 2-5 days and should be transferred, according to the doctor's decision, to taking clarithromycin inwards.

Impaired renal function

Patients with impaired renal function and creatinine clearance (CK) of less than 30 mL / minute should be reduced in half the usual recommended dose of clarithromycin.

Preparation for use

Solution for infusion is prepared as follows:

1) Add 10 ml of sterile water for injection into a vial of 500 mg of lyophilizate. It is recommended that only sterile water for injection, since any other solvent can cause sedimentation. Do not use solvents containing preservatives or inorganic salts.

Note: the prepared solution of the preparation obtained in the manner described above contains a sufficient amount of a preservative and has a concentration of 50 mg / ml of clarithromycin.

Prepared solution of the drug is recommended to use immediately after its preparation. If the solution is not used immediately, it is recommended to keep it for no more than 24 hours at a temperature of 2 ° C to 8 ° C in aseptic conditions.

2) Prior to administration, the prepared solution of the preparation (500 mg in 10 ml of water for injection) should be added to not less than 250 ml of one of the following solutions for IV administration:

5% dextrose solution in Ringer's lactate solution, 5% dextrose solution, Ringer's lactate solution, 5% dextrose solution in 0.3% sodium chloride solution, 5% dextrose solution in 0.45% sodium chloride solution, 0.9% chloride solution sodium.

The resulting solution of the drug is recommended to be used immediately after its preparation. If the solution is not used immediately, it is recommended to keep it for no more than 24 hours at a temperature of 2 ° C to 8 ° C in aseptic conditions. After this period, further storage and use of the solution of clarithromycin IV is not recommended.

Do not mix the solution with any drugs or solvents unless it was primarily

Side effects:

Classification of adverse reactions according to the frequency of development (number of reported cases / number of patients): very often (≥1 / 10), often (≥1 / 100, <1/10), infrequently (≥1 / 1000,<1/100), the frequency is unknown (side effects from the post-marketing application experience, the frequency can not be estimated based on available data).

Allergic reactions

Often: rash.

Infrequently: anaphylactoid reaction¹, hypersensitivity, dermatitis bullous¹, itching, urticaria, maculopapular rash³.

The frequency is unknown: anaphylactic reaction, angioedema, Stevens-Johnson syndrome, toxic epidermal necrolysis, drug rash with eosinophilia and systemic symptomatology (DRESS syndrome).

From the nervous system

Often: headache, insomnia.

Infrequently: loss of consciousness¹, dyskinesia¹, dizziness, drowsiness, tremor, anxiety, increased excitability³.

Frequency is unknown: convulsions, psychotic disorders, confusion, depersonalization, depression, disorientation, hallucinations, dream disturbances ("nightmarish" dreams), paresthesia, mania.

From the skin

Often: intense sweating.

The frequency is unknown: acne, hemorrhage.

From the urinary system

Frequency unknown: renal failure, interstitial nephritis.

From the side of metabolism and nutrition

Infrequent: anorexia, decreased appetite.

From the side of the musculoskeletal system

Infrequently: muscle spasm³, musculoskeletal stiffness¹, myalgia².

Frequency unknown: rhabdomyolysis² *, myopathy.

From the digestive system

Often: diarrhea, vomiting, indigestion, nausea, pain in the abdomen.

Infrequently: esophagitis¹, gastroesophageal reflux disease², gastritis, proctalgia², stomatitis, glossitis, bloating⁴, constipation, dry mouth, eructations, flatulence, cholestasis⁴, hepatitis incl. cholestatic or hepatocellular⁴.

The frequency is unknown: acute pancreatitis, discoloration of the tongue and teeth, hepatic insufficiency, cholestatic jaundice.

From the respiratory system

Infrequently: asthma¹, nose bleed² , pulmonary embolism¹.

From the sense organs

Often: dysgeusia, a taste perversion.

Infrequently: vertigo, hearing impairment, ringing in the ears.

The frequency is unknown: deafness, agevia (loss of taste sensations), parosmia, anosmia.

From the side of the cardiovascular system

Often: vasodilation¹.

Infrequent: cardiac arrest¹, atrial fibrillation¹, prolongation of QT interval on electrocardiogram, extrasystole¹, atrial flutter.

The frequency is unknown: ventricular tachycardia, including the "pirouette" type.

Laboratory indicators

Often: deviation in the hepatic test.

Infrequent: increased creatinine concentration¹, increased urea concentration¹, a change in the albumin-globulin ratio¹, leukopenia, neutropenia⁴, eosinophilia⁴, thrombocythemia³, increased activity: alanine aminotransferase (ALT), aspartate aminotransferase (ACT), gamma glutamyl transferase (GGTP)⁴, alkaline phosphatase⁴, lactate dehydrogenase (LDH)⁴.

The frequency is unknown: agranulocytosis, thrombocytopenia, an increase in the value of the international normalized ratio (MNO), prolongation of prothrombin time, a change in the color of urine, an increase in the concentration of bilirubin in the blood.

General disorders

Very often: phlebitis at the injection site¹.

Often: pain at the injection site¹, inflammation at the injection site¹.

Infrequently: malaise⁴, hyperthermia³, asthenia, chest pain⁴, chills⁴, fatigue⁴.

Infectious and parasitic diseases

Infrequently: cellulite¹, candidiasis, gastroenteritis², secondary infections (including vaginal)³.

The frequency is unknown: pseudomembranous colitis, erysipelas.

Patients with depressed immunity

In patients with AIDS and other immunodeficiency clarithromycin at higher doses for a long time to treat mycobacterial infections, it is often difficult to distinguish the undesirable effects of the drug from the symptoms of HIV infection or a concomitant disease.

The most frequent adverse events in patients taking a daily dose of clarithromycin equal to 1000 mg were: nausea, vomiting, taste distortion, abdominal pain, diarrhea, rash, flatulence, headache, constipation, hearing impairment, increased activity of ACT and ALT in blood. There have also been cases of adverse events with a low incidence, such as shortness of breath, insomnia and dry mouth.

In patients with suppressed immunity, laboratory indicators were evaluated, analyzing their significant deviations from the norm (a sharp increase or decrease). Based on this criterion, 2-3% of patients who received clarithromycin in a dose of 1000 mg daily, there was a significant increase in the activity of ACT and ALT in the blood, as well as a decrease in the number of leukocytes and platelets.A small number of patients also reported an increase in the concentration of residual urea nitrogen.

* In some reports of rhabdomyolysis clarithromycin was taken together with other drugs, the reception of which is known to be associated with the development of rhabdomyolysis (statins, fibrates, colchicine or allopurinol).

¹These adverse reactions were reported only with the use of Clacid®, a lyophilizate for the preparation of a solution for infusion.

²Reports of these adverse reactions were obtained only with the use of Clacid®, sustained-release tablets coated with a film coat.

³Reports of these adverse reactions were obtained only with the use of Clacid®, a powder for the preparation of a suspension for oral administration.

⁴ These adverse reactions were reported only with Clacid®, film-coated tablets.

Overdose:

In case of an overdose, the use of IV clarithromycin should be discontinued and appropriate symptomatic therapy should be started.

Symptoms: there are no reports of cases of overdose with intravenous administration of clarithromycin. Nevertheless, reports indicate that taking a large dose of clarithromycin inside can cause symptoms of impairment from the gastrointestinal tract. In one patient with bipolar disorder in the history after the administration of 8 g of clarithromycin, changes in the mental state, paranoid behavior, hypokalemia and hypoxemia are described.

Treatment: hemodialysis and peritoneal dialysis do not have a significant effect on the concentration of clarithromycin in the serum, which is typical for other drugs of the macrolide group.

Interaction:

The use of the following drugs in conjunction with clarithromycin is contraindicated in connection with the possibility of developing serious side effects

Cisapride, pimozide, terfenadine and astemizole

With the concomitant use of clarithromycin with cisapride, pimozide, terfenadine, or astemizole, an increase in plasma concentrations was reported, which may lead to prolongation of the QT interval and the occurrence of cardiac arrhythmias, including ventricular tachycardia, ventricular fibrillation, and ventricular pirouette tachycardia (see section "Contraindications"),

Alkaloids of ergot

Postmarketing studies show that with the combined use of clarithromycin with ergotamine or dihydroergotamine, the following effects associated with acute poisoning with drugs of the ergotamine group are possible: vascular spasm, ischemia of limbs and other tissues, including the central nervous system. Simultaneous reception of clarithromycin with ergot alkaloids is contraindicated (see section "Contraindications").

Inhibitors of HMG-CoA reductase (statins)

Simultaneous reception of clarithromycin with lovastatin or simvastatin is contraindicated (see the section "Contraindications") due to the fact that these statins are largely metabolized by the isoenzyme CYP3A4, and the combined use with clarithromycin increases their serum concentrations, which leads to an increased risk of myopathy, including rhabdomyolysis. There have been reports of rhabdomyolysis in patients taking clarithromycin together with these drugs. If it is necessary to use clarithromycin, stop taking lovastatin or simvastatin for the duration of therapy.

Clarithromycin should be used with caution in combination therapy with otherstatins. It is recommended to use statins that are independent of the metabolism of the CYP3A isoenzyme (for example, fluvastatin). In case of need for joint intake, it is recommended to take the lowest dose of statin. It should monitor the development of signs and symptoms of myopathy.

The effect of other drugs on clarithromycin

Preparations that are inducers of the isoenzyme CYP3A (eg, rifampicin, phenytoin, carbamazepine, phenobarbital, St. John's wort pitted), can induce the metabolism of clarithromycin. This can lead to a subtherapeutic concentration of clarithromycin, which leads to a decrease in its effectiveness. In addition, it is necessary to monitor the concentration of the inductor of the CYP3A isoenzyme in the blood plasma, which can be increased due to inhibition of the CYP3A isoenzyme by clarithromycin. With the combined use of rifabutin and clarithromycin, there was an increase in plasma rifabutin concentration and a decrease in serum concentration of clarithromycin with an increased risk of uveitis.

The following drugs have a proven or suspected effect on the concentration of clarithromycin in the blood plasma; in the case of their joint application withclarithromycin may require dose adjustments or alternate treatment

Efavirenz, nevirapine, rifampicin, rifabutin and rifapentin

Strong inductors of the cytochrome P450 system, such as efavirenz, nevirapine, rifampicin, rifabutin and rifapentin can accelerate the metabolism of clarithromycin and thus reduce the concentration of clarithromycin in the plasma and weaken the therapeutic effect, and at the same time increase the concentration of the 14-OH-clarithromycin metabolite, which is also microbiologically active. Since the microbiological activity of clarithromycin and 14-OH-clarithromycin differs with respect to different bacteria, the therapeutic effect may decrease with the combined use of clarithromycin and enzyme inducers.

Etravirine

The concentration of clarithromycin decreases with the use of etravirine, but the concentration of the active metabolite of 14-OH-clarithromycin increases. Since 14-OH-clarithromycin has low activity against Mycobacterium avium complex (MAC) infections, the overall activity against these pathogens may change, therefore alternative treatment should be considered for MAC treatment.

Fluconazole

The simultaneous administration of fluconazole at a dose of 200 mg daily and clarithromycin 500 mg twice daily in 21 healthy volunteers resulted in an increase in the mean minimum equilibrium concentration of clarithromycin (C_min) and AUC by 33% and 18% respectively. At the same time, the combined administration did not significantly affect the average equilibrium concentration of the active metabolite of 14-OH-clarithromycin. Correction of the dose of clarithromycin in the case of concurrent administration of fluconazole is not required.

Ritonavir

A pharmacokinetic study showed that a joint intake of ritonavir at a dose of 200 mg every eight hours and clarithromycin at a dose of 500 mg every 12 hours led to a marked suppression of the metabolism of clarithromycin. With the joint administration of ritonavir C_maxclarithromycin increased by 31%, C_minincreased by 182% and AUC increased by 77%. A complete suppression of the formation of 14-OH-clarithromycin was noted. Due to the wide therapeutic range of clarithromycin, a reduction in its dose in patients with normal renal function is not required. In patients with renal insufficiency, it is advisable to consider the following dose adjustment options: with KK 30-60ml / min, the dose of clarithromycin should be reduced by 50%; with QC less than 30 ml / min, the dose of clarithromycin should be reduced by 75%. Ritonavir should not be taken together with clarithromycin in doses exceeding 1 g / day.

Action of clarithromycin on other drugs

Antiarrhythmic drugs (quinidine and disopyramide)

Possible occurrence of ventricular tachycardia of the "pirouette" type when combined use of clarithromycin and quinidine or disopyramide. With concurrent administration of clarithromycin with these drugs, the electrocardiogram should be monitored regularly for prolonged QT intervals, and serum concentrations of these drugs should be monitored.

In post-marketing applications, cases of hypoglycemia were reported with the combined use of clarithromycin and disopyramide. It is necessary to monitor the concentration of glucose in the blood with the simultaneous use of clarithromycin and disopyramide.

Oral hypoglycemic agents / insulin

When combined use of clarithromycin and oral hypoglycemic agents (for example,sulfonylureas) and / or insulin, pronounced hypoglycemia can be observed. Simultaneous use of clarithromycin with some hypoglycemic drugs (for example, nateglinide, pioglitazone, repaglinide and rosiglitazone) can lead to inhibition of the CYP3A isoenzyme by clarithromycin, which can lead to hypoglycemia. Careful monitoring of glucose concentration is recommended.

Interactions caused by the isoenzyme CYP3A

The combined use of clarithromycin, which is known to inhibit the CYP3A isoenzyme, and drugs primarily metabolized by the CYP3A isoenzyme, can be associated with a mutual increase in their concentrations, which may enhance or prolong both the therapeutic and side effects. Clarithromycin should be used with caution in patients receiving drugs that are substrates of the isoenzyme CYP3A, especially if these drugs have a narrow therapeutic range (for example, carbamazepine), and / or are extensively metabolized by this enzyme. If necessary, a dose adjustment of the drug taken with clarithromycin should be performed.Also, if possible, monitoring of serum concentrations of drugs that are primarily metabolized by the CYP3A isoenzyme should be conducted.

Metabolism of the following drugs / classes is carried out by the same isoenzyme CYP3A as the metabolism of clarithromycin, for example, alprazolam, carbamazepine, cilostazol, ciclosporin, disopyramide, methylprednisolone, midazolam, omeprazole, indirect anticoagulants (for example, warfarin), quinidine, rifabutin, sildenafil, tacrolimus, triazolam and vinblastine. Also, the agonists of the CYP3A isoenzyme are the following drugs that are contraindicated for joint use with clarithromycin: astemizole, cisapride, pimozide, terfenadine, lovastatin, simvastatin and ergot alkaloids (see the section "Contraindications"), drugs interacting in a similar way through other isoenzymes within the cytochrome P450 system include phenytoin, theophylline and valproic acid.

Indirect anticoagulants

With the concomitant administration of warfarin and clarithromycin, bleeding is possible, a marked increase in INR and prothrombin time. In the case of combined use with warfarin or other indirect anticoagulants, it is necessary to monitor INR and prothrombin time.

Omeprazole

Clarithromycin (500 mg every 8 hours) was tested in healthy adult volunteers in combination with omeprazole (40 mg daily). With the combined use of clarithromycin and omeprazole, equilibrium plasma concentrations of omeprazole were increased (C_max , AUC_0-24uT_1/2increased by 30%, 89% and 34% respectively). The average pH value of the stomach for 24 hours was 5.2 when taking omeprazole alone and 5.7 when taking omeprazole together with clarithromycin.

Sildenafil, tadalafil and vardenafil

Each of these phosphodiesterase inhibitors is metabolized, at least in part, by the participation of the CYP3A isoenzyme. At the same time, the CYP3A isoenzyme can be inhibited in the presence of clarithromycin. The combined use of clarithromycin with sildenafil, tadalafil or vardenafil may lead to an increase in the inhibitory effect on phosphodiesterase. When using these drugs together with clarithromycin should consider the possibility of reducing the dose of sildenafil, tadalafil and vardenafil.

Theophylline, carbamazepine

With the combined use of clarithromycin and theophylline or carbamazepine, an increase in the concentration of these drugs in the systemic circulation is possible.

Tolterodin

The primary metabolism of tolterodine is via the 2D6 cytochrome P450 isoform (CYP2D6). However, in the part of the population devoid of the isoenzyme CYP2D6, the metabolism occurs through the isoenzyme CYP3A. In this population, suppression of the CYP3A isoenzyme results in significantly higher serum concentrations of tolterodine. In a population with a low level of metabolism via the CYP2D6 isozyme, a dose reduction of tolterodine may be required in the presence of CYP3A isoenzyme inhibitors such as clarithromycin.

Benzodiazepines (e.g., alprazolam, midazolam, triazolam)

When combined with midazolam and clarithromycin tablets (500 mg twice daily), augmentation of midazolam AUC was noted: 2.7 times after intravenous administration of midazolam and 7 times after oral administration. Simultaneous reception of clarithromycin with midazolam for oral administration is contraindicated. If, together with clarithromycin, the intravenous form of midazolam is used, the patient's condition should be carefully monitored for possible dose adjustment. The same precautions should also be applied to other benzodiazepines that are metabolized by the CYP3A isoenzyme, including triazolam and alprazolam. For benzodiazepines, the excretion of which does not depend on the isoenzyme CYP3A (temazepam, nitrazepam, lorazepam), clinically significant interaction with clarithromycin is unlikely.

With the combined use of clarithromycin and triazolam, an effect on the central nervous system (CNS) is possible, for example, drowsiness and confusion. In this regard, in the case of joint application, it is recommended to follow the symptoms of the CNS disorder.

Interactions with other drugs

Aminoglycosides

With the simultaneous administration of clarithromycin with other ototoxic drugs, especially aminoglycosides, care must be taken to monitor the functions of the vestibular and hearing aids both during therapy and after its termination.

Colchicine

Colchicine is a substrate for both the CYP3A isoenzyme and the P-glycoprotein carrier protein (Pgp). It is known that clarithromycin and other macrolides are inhibitors of the isoenzyme CYP3A and Pgp. When co-administered with clarithromycin and colchicine, inhibition of Pgp and / or isoenzyme CYP3A can lead to increased colchicine action. It should monitor the development of clinical symptoms of colchicine poisoning. Post-marketing reports on cases of colchicine poisoning during its simultaneous administration with clarithromycin are registered, more often in elderly patients.

Some of these cases occurred with patients suffering from kidney failure. As reported, some cases ended in a fatal outcome.

Simultaneous use of clarithromycin and colchicine is contraindicated (see section "Contraindications").

Digoxin

It is assumed that digoxin is the substrate of Pgp. It is known that clarithromycin inhibits Pgp. When co-administered with clarithromycin and digoxin, inhibition of Pgp with clarithromycin may lead to an increase in the action of digoxin. The combined use of digoxin and clarithromycin can also lead to an increase in serum digoxin concentration. Some patients experienced clinical symptoms of digoxin poisoning, including potentially fatal arrhythmias. When co-administered with clarithromycin and digoxin, the concentration of digoxin in the serum should be carefully monitored.

Zidovudine

Simultaneous reception of tablets of clarithromycin and zidovudine by oral HIV-infected adults can lead to a decrease in the equilibrium concentration of zidovudine.

Because the clarithromycin influences the absorption of zidovudine when taken orally, interactions can be largely avoided by taking clarithromycin and zidovudine with an interval of 4 hours.

Similar interaction was not observed in HIV-infected children who took a children's suspension of clarithromycin with zidovudine or dideoxyinosine. Because the clarithromycin may interfere with the absorption of zidovudine when administered simultaneously in adults in adults, this interaction is hardly possible with the use of clarithromycin intravenously.

Phenytoin and valproic acid

There are data on the interactions of inhibitors of the isoenzyme CYP3A (including clarithromycin) with drugs that are not metabolized by the CYP3A isoenzyme (phenytoin and valproic acid). For these drugs, when combined with clarithromycin, it is recommended to determine their serum concentrations, since there are reports of their increase.

Bi-directional drug interactions

Atazanavir

Clarithromycin and atazanavir are both substrates and inhibitors of the CYP3A isoenzyme. There is evidence of bi-directional interaction of these drugs.

The combined use of clarithromycin (500 mg twice daily) and atazanavir (400 mg once a day) can lead to a twofold increase in the effect of clarithromycin and a reduction in the effect of 14-OH-clarithromycin by 70%, with an increase in Atazanavir AUC by 28%. Due to the wide therapeutic range of clarithromycin, a reduction in its dose in patients with normal renal function is not required. In patients with moderate renal failure (CK 30-60 ml / min), the dose of clarithromycin should be reduced by 50%. In patients with QC less than 30 ml / min, the dose of clarithromycin should be reduced by 75% using the appropriate dosage form of clarithromycin. Clarithromycin in doses exceeding 1000 mg per day, can not be used in conjunction with protease inhibitors.

Blocks of "slow" calcium channels

With the simultaneous use of clarithromycin and blockers of "slow" calcium channels, which are metabolized by the isoenzyme CYP3A4 (for example, verapamil, amlodipine, diltiazem), you should be careful, since there is a risk of arterial hypotension. Plasma concentrations of clarithromycin, as well as blockers of "slow" calcium channels, can increase with simultaneous application.Arterial hypotension, bradyarrhythmia and lactic acidosis are possible with concurrent administration of clarithromycin and verapamil.

Itraconazole

Clarithromycin and itraconazole are substrates and inhibitors of the CYP3A isoenzyme, which determines the bi-directional interaction of the drugs. Clarithromycin can increase the concentration of itraconazole in the plasma, while itraconazole can increase the plasma concentration of clarithromycin. Patients simultaneously taking itraconazole and clarithromycin, should be carefully examined for signs of increased or prolonged pharmacological effects of these drugs.

Saquinavir

Clarithromycin and saquinavir are substrates and inhibitors of the CYP3A isoenzyme, which determines the bi-directional interaction of the drugs. The simultaneous use of clarithromycin (500 mg twice daily) and saquinavir (in soft gelatin capsules, 1200 mg three times daily) in 12 healthy volunteers caused an increase in AUC and C_maxsaquinavir by 177% and 187%, respectively, compared with the administration of saquinavir alone. The values of AUC and C_maxclarithromycin were approximately 40% higher than with monotherapy with clarithromycin.When these two drugs are used together for a limited time in the doses / formulations mentioned above, dose adjustment is not required. The results of a study of drug interactions using saquinavir in soft gelatin capsules may not correspond to the effects observed with saquinavir in hard gelatin capsules. The results of the study of drug interactions with saquinavir monotherapy may not correspond to the effects observed with saquinarine / ritonavir therapy. When taking saquinavir together with ritonavir, the potential effect of ritonavir on clarithromycin.

Special instructions:

Long-term use of antibiotics can lead to the formation of colonies with an increased number of insensitive bacteria and fungi. When superinfection is necessary to appoint appropriate therapy.

When applying clarithromycin, hepatic dysfunction was reported (increased hepatic enzyme activity in the blood, hepatocellular and / or cholestatic hepatitis with or without jaundice). Hepatic dysfunction can be severe, but is usually reversible.There are cases of hepatic insufficiency with a fatal outcome, usually associated with the presence of serious concomitant diseases and / or simultaneous use of other medications. When signs and symptoms of hepatitis such as anorexia, jaundice, darkening of the urine, itching, tenderness of the abdomen during palpation, it is necessary to immediately stop the treatment with clarithromycin. In the presence of chronic liver diseases it is necessary to carry out regular monitoring of serum enzymes.

In the treatment of nearly all antibacterial agents, including clarithromycin, described cases of pseudomembranous colitis, the severity of which can range from mild to life-threatening. Antibiotic drugs can change the normal intestinal microflora, which can lead to growth C. difficile. Pseudomembranous colitis caused by Clostridium difficile, It is necessary to suspect all patients experiencing the appearance of diarrhea after using antibacterial agents. After the course of antibiotic therapy, careful medical supervision of the patient is necessary.Cases of pseudomembranous colitis after 2 months after taking antibiotics were described.

Clarithromycin should be used with caution in patients with ischemic heart disease (CHD), severe heart failure, hypomagnesemia, severe bradycardia (less than 50 beats / min), and also with simultaneous use with antiarrhythmic drugs IA class (quinidine, procainamide) and III class (dofetilide, amiodarone, sotalol). With these conditions and with the simultaneous administration of clarithromycin with these drugs, the electrocardiogram should be monitored regularly for longer intervals QT.

It is possible to develop cross-resistance to clarithromycin and other antibiotics of the macrolide group, as well as to lincomycin and clindamycin.

Given the growing resistance Streptococcus pneumoniae to macrolides, it is important to conduct sensitivity testing in the appointment of clarithromycin to patients with community-acquired pneumonia. With hospital pneumonia clarithromycin should be used in combination with appropriate antibiotics.

Infections of the skin and soft tissues of mild and moderate severity are most often caused Staphylococcus aureus and Streptococcus pyogenes. In this case, both pathogens can be resistant to macrolides. Therefore, it is important to carry out a sensitivity test.

Macrolides can be used for infections caused by Corynebacterium minutissimum, diseases acne vulgaris and erysipelas, as well as in those situations where penicillin can not be used.

In the case of acute hypersensitivity reactions, such as anaphylactic reaction, Stevens-Johnson syndrome, toxic epidermal necrolysis and drug rash with eosinophilia and systemic symptoms (DRESS-syndrome) should immediately stop taking clarithromycin and begin appropriate therapy.

In the case of joint use with warfarin or other indirect anticoagulants, it is necessary to monitor INR and prothrombin time (see the section "Interaction with other drugs").

Effect on the ability to drive transp. cf. and fur:

Data on the effect of clarithromycin on the ability to control vehicles and mechanisms are not available.

Care should be taken when driving vehicles and mechanisms, taking into account the potential for dizziness, vertigo, confusion and disorientation that may occur when using this drug.

Form release / dosage:

Lyophilizate for solution for infusion, 500 mg.

Packaging:

Lyophilizate in a glass vial of colorless glass, sealed with a cork made of bromobutyl rubber, which is fixed with an aluminum cap with a plastic lid.

1 bottle with instructions for use in a cardboard box.

Storage conditions:

Store in a dark place at a temperature of 15 to 30 ° C.

Keep out of the reach of children.

Shelf life:

3 years.

Do not use after the expiration date.

Terms of leave from pharmacies:On prescription

Registration number:П N012673 / 01

Date of registration:03.10.2011

The owner of the registration certificate:Abbott FranceAbbott France France

Manufacturer: & nbsp

FAMAR L 'Aigle France

VEROPHARM SA Russia

Representation: & nbspABBOTT LABORATORIES LLC ABBOTT LABORATORIES LLC Russia

Information update date: & nbsp29.08.2014

Illustrated instructions

Instructions

Clacid® (Klacid®)