http___www.krenizdravo.com_korisno_upute_ketonal-forte-100-mg-tablete_1.xml
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Each tablet contains 500mg Nabumetone. Film-coated tablet Maroon, oval, biconvex, film-coated tablets impressed C on one face and the identifying letters NB on the reverse. Nabumetone Tablets are indicated for use in osteoarthritis and rheumatoid arthritis requiring anti-inflammatory and analgesic treatment. PosologyAdults: The usual starting dose is 1g (two tablets) per day taken as a single daily dose at bedtime. For severe or persistent symptoms, or during acute exacerbations an additional 500mg- 1g may be given as a morning dose. Elderly: Blood levels may be higher in elderly patients because of accumulation of the drug as a result of reduced metabolism and elimination by the liver and kidneys. The recommended daily dose of 1g should not be exceeded in this age group and in some cases 500mg may give satisfactory relief. The risk of serious consequences of adverse effects is increased in the elderly. The lowest dose possible should be used and patients should be monitored for gastrointestinal bleeding for 4 weeks following initiation of therapy with nabumetone. Children: Not recommended as there is no clinical data. Method of Administration For oral administration. Nabumetone should be administered with or after food to minimise the risk of gastrointestinal adverse effects. Undesirable effects may be minimised by using the lowest effective dose for the shortest duration necessary to control symptoms (see section 4.4). Nabumetone Tablets should not be given under the following circumstances: • Known hypersensitivity to nabumetone, non-steroidal anti-inflammatory drugs or other ingredients in the tablet. • Patients in whom acetylsalicylic acid or other non-steroidal anti-inflammatory agents precipitate asthmatic attacks, angioedema, urticaria, acute rhinitis or allergic-type reactions. Severe, rarely fatal, anaphylactic-like reactions to NSAIDs have been reported in such patients. • Patients with active peptic ulceration or a history of peptic ulcer disease (2 or more distinct episodes) of recurrent or current GI haemorrhage, perforation or peptic disease. • Patients with a history of upper gastrointestinal bleeding or perforation, related to previous NSAID therapy. • Patients with severe hepatic or renal impairment (eg cirrhosis). • Patients with severe heart failure and in patients with current cerebrovascular or other haemorrhage. • Nabumetone should not be used in patients with uncorrected coagulation defects due to an increase in the risk of gastrointestinal bleeding. • During the last trimester of pregnancy and in nursing mothers (see section 4.6). Caution should be taken when prescribing nabumetone in the following circumstances: • Co-administration of nabumetone and other NSAIDs, COX II inhibitors or aspirin increases the risk of adverse effects and such combinations should be avoided. • Undesirable effects may be minimised by using the lowest effective dose for the shortest duration necessary to control symptoms (see section 4.2, and GI and cardiovascular risks below). • Elderly The elderly have an increased frequency of adverse reactions to NSAIDs especially gastrointestinal bleeding and perforation which may be fatal (see section 4.2). • Gastrointestinal disorders GI bleeding, ulceration or perforation, which can be fatal, has been reported with all NSAIDs at any time during treatment, with or without warning symptoms or previous history of serious GI events. When GI bleeding or ulceration occurs in patients receiving nabumetone the treatment should be withdrawn. The risk of GI bleeding, ulceration or perforation is higher with increasing NSAID doses, in patients with a history of ulcer, particularly if complicated with haemorrhage or perforation (see section 4.3), and in the elderly. These patients should commence treatment at the lowest dose available. Combination therapy with protective agents (e.g. misoprolol or proton pump inhibitors) should be considered for these patients, and also for patients requiring concomitant low dose acetylsalicylic acid, or other drugs likely to increase gastrointestinal risk (See below and 4.5). Patients with a history of GI toxicity, particularly the elderly, should report any unusual abdominal symptoms (especially GI bleeding) particularly in the initial stages of treatment. Caution should be advised in patients receiving concomitant medications which could increase the risk of gastrotoxicity or bleeding, such as corticoseroids, anticoagulants such as warfarin or anti-platelet agents such as aspirin and clopidogrel (see section 4.5). Nabumetone should be used with caution in patients with a history of gastrointestinal disease (ulcerative colitis, Crohn's disease) as these conditions may be exacerbated (see section 4.8). In patients with active peptic ulcer, physicians must weigh the benefits of therapy with nabumetone against possible hazards, institute an appropriate ulcer treatmetnregimen and monitor the patients' progress carefully. Nabumetone is better tolerated than most other NSAIDs, primarily because it results in fewer effects on the gastrointestinal (GI) system. In a review of both pre- and post-registration data from trials with nabumetone, the mean cumulative frequencies of GI perforations, ulcers or bleeds (PUBs) in patients treated from 3 to 6 months, 1 year and 2 years were respectively 0.3%, 0.5% and 0.8%; although these figures are lower than those ascribed to other NSAIDs, the prescribing physician should be aware that these ADRs can occur even in the absence of previous peptic disease. When GI bleeding or ulceration occurs in patients receiving Nabumetone, the treatment should be withdrawn. • Cardiovascular and cerebrovascular effects Appropriate monitoring and advice are required for patients with a history of hypertension and/or mild to moderate congestive heart failure as fluid retention and oedema have been reported in association with NSAID therapy. Clinical trial and epidemiological data suggest that use of some NSAIDs (particularly at high doses and in long term treatment) may be associated with a small increased risk of arterial thrombotic events (for example myocardial infarction or stroke). There are insufficient data to exclude such a risk for Nabumetone. Patients with uncontrolled hypertension, congestive heart failure, established ischaemic heart disease, peripheral arterial disease, and/or cerebrovascular disease should only be treated with Nabumetone after careful consideration. Similar consideration should be made before initiating longer-term treatment of patients with risk factors for cardiovascular disease (e.g. hypertension, hyperlipidaemia, diabetes mellitus, smoking). • Administration of nabumetone can lower serum thyroid hormone levels and can affect the interpretation of thyroid function tests. • Impaired female fertility The use of nabumetone may impair female fertility and is not recommended in women attempting to conceive. In women who have difficulties conceiving or who are undergoing investigation of infertility, withdrawal of nabumetone should be considered. • Cases of blurred vision or reduced visual activity have been reported with NSAID use, including nabumetone. Patients presenting with these events must be submitted to ophtalmological examination. Despite the relative gastrointestinal and renal safety of nabumetone, caution should be used when administering to patients with: • active upper GI ulceration. Appropriate treatment should be instigated prior to initiating nabumetone therapy. • history of upper GI ulceration. The patient should be alerted to report symptoms indicative of ulceration. • other therapies known to increase the risk of gastrointestinal ulcer (e.g., oral corticosteroids ). • fluid retention, hypotension, a history of hypertension and/or heart failure. Fluid retention and peripheral oedema have been reported in association with NSAID therapy and the patients should be monitored for exacerbation of the excisting condition and appropriate therapy instigated if warranted. • previous acetylsalicylic acid- or other NSAID-induced asthma, urticaria or other allergic type reactions. Since fatal asthma attacks have been reported in such patients receiving other NSAIDs, the first administration of nabumetone should be medically supervised. Additionally, nabumetone should be used with caution in patients suffering from or with a history of asthma as NSAIDs have been reported to precipitate broncospasm in such patients. • severe renal impairment (creatinine clearance less than 30ml/min) should have laboratory tests performed at base line and within some weeks of starting therapy. If the impairment worsens discontinuation of therapy may be warranted, as the renal route is the major excretion route for the metabolites of nabumetone. In patients with moderate renal function impairment (creatinine clearance 30 to 49ml/min) there is a 50% increase in unbound plasma 6-MNA and dosage reduction should be considered (see section 4.5). • severe hepatic impairment. As with other NSAIDs, abnormalities of liver function tests, rare cases of jaundice and hepatic failure (some of them with fatal outcomes) have been reported. A patient with signs/symptoms suggesting liver dysfunction or who has experienced an abnormal liver function test while on nabumetone therapy should be evaluated for evidence of development of a more serious hepatic reaction. Nabumetone should be discontinued if such a reaction occurs. • infections as it may mask symptoms such as fever and inflammation. • systemic lupus erythromatosus (SLE) and mixed connective tissue disorders there may be an increased risk of aseptic meningitis (see section 4.8). • serious skin reactions, some of them fatal, including exfoilative dermatitis, Stevens-Johnson syndrome, and toxic epidermal necrolysis, have been reported very rarely in association with the use of NSAIDs (see 4.8). Patients appear to be at highest risk of these reactions early in the course of therapy, the onset of the reaction occurring in the majority of cases within the first months of treatment. Nabumetone should be discontinued at the first appearance of skin rash, mucosal lesions, or any other sign of hypersensitivity. Caution should be taken if concurrent administration of any of the following drugs or groups of drugs is indicated. • ACE inhibitors and angiotensin II receptor antagonists Co-administration of NSAIDs and ACE inhibitors and angiotensin II receptor antagonists is associated with an increased risk of renal impairment due to decreased renal perfusion. Prostaglandins may be involved in the antihypertensive effects of these drugs and inhibition of prostaglandin synthetase by NSAIDs may antagonise these effects. The risk of hyperkalaemia may be increased in patients taking ACE inhibitors or angiotensin II receptor antagonists with NSAIDs. In some persons (such as elderly or dehydrated patients) this could lead to a further decrease in renal function and eventually to ARF. Consequently, hydration and frequent monitoring of these patients is warranted. • Adrenergic neurone blockers NSAIDs may antagonise the hypotensive effects of adrenergic neurone blockers. • Alcohol Alcohol may increase the risk of gastrointestinal bleeding and ulceration in patients taking NSAIDs. • Analgesics Concurrent administration of nabumetone with other NSAIDs, including aspirin, is contraindicated because of the risk of additive adverse effects on the gastrointestinal tract (see section 4.3). • Antibacterials Isolated reports of convulsions or other neurological toxicity and skin eruptions have been noted in patients taking NSAIDs when quinolones are added to their therapy. The risk appears to be small but concurrent use should be monitored carefully in epileptic patients. Decreased renal clearance with correspondingly increased toxicity has been observed in patients taking NSAIDs and aminoglycosides concurrently. • Anticoagulants The effects of coumarins , phenindione and heparins may be enhanced by concurrent administration with NSAIDs. The combination should be used with care as NSAIDs have an effect on platelet activity and can affect bleeding times. NSAIDs also increase the risk of gastrointestinal bleeding and ulceration in patients taking anticoagulants. Nabumetone specifically does not usually interact with warfarin or acenocoumarol but isolated cases of increases in INR and haemarthrosis have been noted so concurrent use should be monitored carefully. • Antidepressants The risk of bleeding may be increased when NSAIDs are administered concurrently with SSRIs , venlafaxine or moclobemide • Antidiabetics NSAIDs such as nabumetone which are highly protein bound can displace sulphonylureas from binding sites with a corresponding increase in hypoglycaemic activity. Rosiglitazone can cause fluid retention which can exacerbate or precipitate heart failure. • Antiepileptics NSAIDs such as nabumetone which are highly protein bound can displace phenytoin from binding sites with a corresponding increase in the risk of phenytoin toxicity. • Antivirals Plasma levels of NSAIDs may be increased in patients taking ritonavir The risk of haematological toxicity may be increased when NSAIDs are co-administered with zidovudine and blood counts are recommended for 1 to 2 weeks after starting concurrent therapy. • Beta blockers Co-administration of NSAIDs with beta blockers can result in an antagonism of antihypertensive activity. This is due to an increased risk of renal impairment due to decreased renal perfusion. Prostaglandins may be involved in the antihypertensive effects of beta blockers and inhibition of prostaglandin synthetase by NSAIDs may antagonise this activity. • Bisphosphonates The risks of oesophagitis and gastrointestinal bleeding and ulceration are increased by concomitant administration of NSAIDs and bisphosphonates and co-administration should be avoided. • Calcium channel blockers The antihypertensive activity of calcium channel blockers may be antagonised by NSAIDs. • Cardiac glycosides Plasma levels of digoxin may be increased in patients taking NSAIDs with a corresponding increase in the risk of toxicity. NSAIDs may exacerbate the decline in renal function in susceptible patients, such as the elderly, leading to an increased risk of heart failure. • Clonidine The antihypertensive effects of clonidine may be antagonised by concurrent administration of NSAIDs. • Clopidrogel The risk of gastrointestinal bleeding is increased by concomitant administration of NSAIDs and clopidrogel. • Corticosteroids The risk of gastrointestinal bleeding and ulceration is increased by concomitant administration of NSAIDs and corticosteroids. • Cytotoxics Concomitant use of NSAIDs and methotrexate should be monitored closely, especially in patients with compromised renal function. NSAIDs inhibit renal perfusion as a result of their effects on prostaglandin synthetase. This results in a reduction in the renal excretion of methotrexate with a corresponding increase in the risk of methotrexate toxicity. In addition, highly protein bound NSAIDs may displace methotrexate from protein binding sites to enhance the risk of methotrexate toxicity. • Diuretics There is a reduced diuretic effect. The antihypertensive effects of diuretics are antagonised by concomitant administration with NSAIDs due to the effects of NSAIDs on prostaglandin synthetase activity in the kidney. The risk of adverse effects is greatest in patients with cirrhosis, cardiac failure and/or renal insufficiency. The risk of hyperkalaemia may be increased in patients taking potassium sparing diuretics and NSAIDs concomitantly because of the effects of NSAIDs on renal function. • Immunosuppressants The risk of nephrotoxicity is increased when ciclosporin and NSAIDs are administered concomitantly. The inhibition of prostaglandin synthetase by NSAIDs in the kidney may result in a reduction of glomerular filtration rate and renal blood flow required to protect the kidney from the nephrotoxic effects of ciclosporin. Similar effects may be observed in patients taking tacrolimus and NSAIDs concurrently. • Lithium The inhibition of renal prostaglandins by NSAIDs reduces renal blood flow. This reduces the renal excretion of lithium with a resultant increase in plasma levels and an increased risk of lithium toxicity. Concomitant administration of lithium and NSAIDs should be monitored carefully and avoided whenever possible. • Methyldopa The antihypertensive effects of methyldopa may be antagonised by concurrent administration of NSAIDs. • Mifepristone There is a theoretical risk that NSAIDs will reduce the efficacy of mifepristone because of their inhibitory effects on prostaglandin synthetase and it is recommended that administration of NSAIDs should be avoided for 8 to 12 days after the use of mifepristone. • Muscle relaxants The renal excretion of baclofen may be inhibited when it is co-administered with NSAIDs with a possible increase in the risk of toxicity. • Nitrates The hypotensive effects of nitrates may be antagonised by concurrent administration of NSAIDs. • Pentoxifylline The risk of gastrointestinal bleeding and ulceration may be increased by concomitant administration of NSAIDs and pentoxifylline. • Progestogens The risk of hyperkalaemia may be increased by concomitant administration of drospirenone with NSAIDs and serum potassium should be monitored during the first treatment cycle. • Sibutramine The risk of gastrointestinal bleeding is enhanced when NSAIDs are administered concomitantly with sibutramine. • Vasodilators Co-administration of NSAIDs with hydralazine, minoxidil or nitroprusside can result in antagonism of hypotensive activity. This is due to an increased risk of renal impairment due to decreased renal perfusion. Prostaglandins may be involved in the hypotensive effects of these vasodilators and inhibition of prostaglandin synthetase by NSAIDs may antagonise this activity. The following commonly available drugs do not affect nabumetone metabolism and bioavailability: paracetamol, cimetidine and aluminium hydroxide antacids. Concomitant administration of nabumetone with other protein-bound drugs, e.g. sulphonamides and hydantoin should be undertaken with caution and overdose signals carefully monitored. Pregnancy Safety of nabumetone in human pregnancy has not been established. Use of NSAIDs in women prior to conception may lead to an increased risk of miscarriage. Until further studies verify the risks to the unborn child, women of childbearing age planning pregnancy should be advised to avoid taking nabumetone when trying to conceive a child. The investigators thought that this was due to the inhibitory effects of NSAIDs on prostaglandin synthetase. Prostaglandins are necessary for successful implantation into the uterine wall and are also involved in the ovulation process. It would be prudent to advise women hoping to conceive to take an alternative analgesic, such as paracetamol. NSAIDs are also associated with an increased risk of spontaneous abortion. Use of NSAIDs during the first and second trimester of pregnancy should be avoided because of possible adverse effects on the fetus, such as congenital abnormalities such as premature closure of the ductus arteriosus, which may lead to pulmonary hypertension in the newborn these are low in frequency and do not appear to follow any discernible pattern. NSAIDs have been associated with a delayed onset and increased duration of labour with an increased bleeding tendency in both mother and child (see section 4.3). NSAIDs should not be used during the first two trimesters of pregnancy or labour unless the potential benefit to the patients outweighs the potential risk to the foetus. Use of nabumetone is contraindicated in the third trimester of pregnancy. The known effects of NSAIDs on the human foetus during the third trimester of pregnancy include adverse effects such as premature closure of the ductus arteriosus, which may lead to pulmonary hypertension in the newborn, and pulmonary and cardiac changes. These are low in frequency and do not appear to follow any discernible pattern. Lactation: It is not known whether nabumetone is excreted in human milk; however, 6MNA is excreted in the milk of lactating rats. With the potential for serious adverse reactions in breast fed infants from nabumetone, a decision should be made whether to discontinue breast feeding or to discontinue the drug, taking into account the importance of the drug to the mother. See section 4.4 for information on female fertility. As nabumetone can cause visual disturbances, drowsiness, dizziness, confusion and headache, patients should make sure they are not affected before driving or operating machinery. In clinical trials increases in dose above 1g did not lead to an increase in the incidence of side effects. However, the lowest effective dose should always be used. Adverse events are listed below by system organ class and frequency. Frequencies are defined as: very common (≥ 1/10), common (≥ 1/100 and < 1/10), uncommon (≥ 1/1000 and < 1/100), rare (≥ 1/10,000 and < 1/1000) and very rare (< 1/10,000), including isolated reports. Very common, common and uncommon events were generally determined from clinical trial data. The incidence in placebo and comparator groups has not been taken into account in estimation of these frequencies. Rare and very rare events were generally determined from spontaneous data. • Blood and lymphatic system disorders Very rare: Blood dyscrasias including leucopenia, thrombocytopenia, neutropenia, agranulocytosis, aplastic anaemia and haemolytic anaemia. • Immune system disorders Very rare: anaphylaxis and anaphylactoid reactions. Skin reactions may be urticarial, macropapular, vesicular or exfoliative. Pruritus, rash, urticaria, photosensitivity reactions including pseudoporphyria, severe skin eruptions (eg Stevens Johnson syndrome), erythema multiforme and toxic epidermal necrolysis have been reported very rarely. They are probably of phototoxic origin and may be associated with systemic hypersensitivity or other allergic reaction. Skin pigmentation and environmental factors also determine the risk of phototoxic reactions. Serious allergic reactions involving the skin may have a genetic component. Non-specific allergic reactions, including vasomotor rhinitis, angioedema, bronchospasm, asthma and dyspnoea have been reported. Alveolitis and pulmonary eosinophilia have been reported rarely as an allergic response to NSAIDs. Pancreatitis has been reported. Reports of aseptic meningitis (especially in patients with existing auto-immune disorders, such as systemic lupus erythematosus or mixed connective tissue disease) with symptoms such as stiff neck, headache, nausea, vomiting, fever or disorientation (see section 4.4). • Psychiatric disorders Uncommon: Confusion, nervousness, insomnia. Depression and hallucinations have been reported. • Nervous system disorders Uncommon: Headache, dizziness, paraesthesia, somnolence. Sedation, fatigue, vertigo, drowsiness and malaise have been reported. • Eye disorders Uncommon: Abnormal vision, eye disorders (optic neuritis, ocular discomfort and irritation, papilloedema and optic or retrobulbar neuritis). • Ear and labyrinth disorders Common: Tinnitus, ear disorders. • Cardiac disorders Oedema. Heart failure has been reported in elderly patients. Oedema, hypertension, and cardiac failure, have been reported in association with NSAID treatment. • Respiratory, thoracic and mediastinal disorders Uncommon: Dyspnoea, respiratory disorder, epistaxis. Very rare: Intersitial pneumonitis. • Gastrointestinal disorders The most commonly observed adverse effects associated with NSAID administration are gastrointestinal in nature. All NSAIDs can cause damage to the gastrointestinal mucosa. Gastrointestinal adverse effects are due to central activities of NSAIDs as well as local effects on the mucosa. Risk factors are age, history of ulcers and/or gastrointestinal bleeding, use of NSAIDs in combination with corticosteroids or with other NSAIDs. Sex (female), the musculoskeletal disease being treated and the NSAID taken and dosage used also affect the risk of developing gastrointestinal adverse effects. Treatment with NSAIDs should begin with a low dose. Common: Diarrhoea, constipation, dyspepsia, gastritis, nausea, abdominal pain, flatulence. Uncommon: Dry mouth, stomatitis, vomiting, melaena, haematemesis gastrointestinal ulceration, bleeding or perforation. Induction or exacerbation of colitis and Crohn's disease and erosive and/or ulcerative oesophagitis, ulceration of the oesophagus with or without bleeding and/or oesophageal perforation or strictures have been reported in patients taking NSAIDs, usually as long term therapy. Severe intestinal bleeding and perforation are very rare complications of long term therapy with NSAIDs. Perforation can lead to peritonitis and death. • Hepato-biliary disorders Very rare: Hepatic failure, jaundice. NSAIDs are also associated with hepatitis. • Skin and subcutaneous tissue disorders Common: Rash, pruritus. Uncommon: Photosensitivity, urticaria (sometimes associated with angioedema), sweating. Very rare: Bullous reactions including Stevens-Johnson syndrome and toxic epidermal necrolysis, alopecia, pseudoporphyria, erythema multiforme, angioedema. NSAIDs can exacerbate pre-existing skin diseases, such as acne and psoriasis, on rare occasions. • Musculoskeletal and connective tissue disorders Uncommon: myopathy. • Renal and urinary disorders All NSAIDs have the potential to cause nephrotoxicity. This results from haemodynamic changes that occur secondary to the inhibition of prostaglandin synthetase in the kidney. Patients at particular risk include those with pre-existing renal impairment and hypertensive renal disease who require long term treatment with NSAIDs. NSAIDs with long half lives, such as nabumetone, are associated with a greater potential to cause nephrotoxicity. Uncommon: Urinary tract disorder. Very rare: Renal failure, acute interstitial nephritis, distinguished by a nephrotic syndrome that is often accompanied by renal insufficiency, has been reported in patients on long term therapy with NSAIDs. Functional renal insufficiency is the most common adverse effect of NSAIDs on the renal system. It is usually mild and reversible within a few days of withdrawing NSAID therapy. Renal papillary necrosis has also been reported in patients on long term NSAID therapy. Haematuria has been reported. • Reproductive system and breast disorders Very rare: Menorrhagia NSAIDs can affect fertility in women hoping to conceive (see section 4.6). • General disorders and administrative site conditions Common: Oedema Uncommon: Asthenia, fatigue. • Investigations Uncommon: Elevated liver function tests. Clinical trial and epidemiological data suggests that use of some NSAIDs (particularly at high doses and in long term treatment) may be associated with an increased risk of arterial thrombotic events (for example myocardial infarction or stroke (see section 4.4). Symptoms: headache, nausea, vomiting, epigastric pain, gastrointestinal bleeding, rarely diarrhoea, disorientation, excitation, coma, drowsiness, dizziness, tinnitus, fainting, occasionally convulsions. In cases of significant poisoning acute renal failure and liver damage are possible. There is no specific antidote and the active metabolite 6-MNA is not dialysable. Treatment: patients should be treated symptomatically as required. Within one hour of ingestion of a potentially toxic amount, activated charcoal should be considered. Alternatively, in adults, gastric lavage should be considered. Good urine output should be ensured. Renal and liver function should be closely monitored. Patients should be observed for at least four hours after ingestion of potentially toxic amounts. Frequent or prolonged convulsions should be treated with intravenous diazepam. ATC code M01A X01. Nabumetone is a non-acidic NSAID which is a relatively weak inhibitor of prostaglandin synthesis. Following absorption from the gastrointestinal tract nabumetone is rapidly metabolised in the liver to the principal active metabolite, 6-methoxy-2-naphylacetic acid (6-MNA) a potent inhibitor of prostaglandin synthesis. Nabumetone is a naproxen derivative and 6-MNA is structurally similar to naproxen. The pharmacokinetic properties of nabumetone are summarised in the table below: Absorption Although nabumetone is absorbed essentially intact through the small intestine, extensive metabolism occurs during the first pass through the liver. As a result, concentrations in plasma of nabumetone are barely detectable after oral dosage. Distribution Intravenous studies in rats with nabumetone indicate it to be rapidly distributed throughout the body, in keeping with its highly lipophilic character. Metabolism and elimination The active metabolite, 6-MNA, blinds strongly to plasma proteins; it is distributed into inflamed tissue and crosses the placenta into foetal tissue. It is found in the milk of lactating females. 6-MNA is eliminated by metabolism, principally conjugation with glucuronic acid, and O-demethylation followed by conjugation, the main route of excretion being the urine. The mean plasma elimination half life of 6-MNA is about 22 hours in man. No mutagenic activity was demonstrated in the Ames test or the mouse micronucleus test in vivo However, chromosomal aberrations occurred in lymphocytes exposed in vitro to nabumetone or its active metabolite 6-MNA at concentrations of 80ug/ml or higher. Nabumetone produced no carcinogenic effects in rats or mice in life time studies. No teratogenic potential has been demonstrated in experiments with animals. High doses (rabbit, 300mg/kg) which were maternally toxic were also embryotoxic. High doses in rats (320mg/kg) delayed parturition (probably due to an inhibition of prostaglandin synthesis). The active metabolite of nabumetone 6-MNA is distributed into milk of lactating rats in concentrations approximately equal to those in plasma. The tablets also contain: microcrystalline cellulose 101 (E460), hydroxypropylmethylcellulose (E464), sodium lauryl sulphate, sodium starch glycollate, colloidal silica, magnesium stearate. The coating contains: hydroxypropylmethylcellulose (E464), propylene glycol, purified talc (E553), carmoisine aluminium lake (E122), indigo carmine aluminium lake (E132), titanium dioxide (E171). Three years from the date of manufacture. Store in the original container. The blister packs are manufactured from 250µm white rigid PVC and 20µm hard temper aluminium foil. The polypropylene containers are manufactured from rigid injection moulded polypropylene with snap-on polyethylene lids. Pack sizes: 28s, 56s, 84s, 112s (blisters) Actavis UK Limited (Trading style: Actavis) Whiddon Valley BARNSTAPLE N Devon EX32 8NS 1 November 1999
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SASTAV 1 filmom obložena tableta sadržava 100 mg ketoprofena. Pomoćne tvari: Jezgra: kukuruzni škrob, laktoza monohldrat Ovojnica: hipromeloza, plava boja indigotin (E132), titan-dioksid (E171). FARMACEUTSKI OBLIK I SADRŽAJ PAKIRANJA filmom obložene tablete (svjetlo plave, okrugle, bikonveksne tablete) FARMAKOTERAPIJSKA SKUPINA nesteroidni protuupalni pripravci, ketoprofen IME I ADRESA PROIZVOĐAČA Lek farmacevtska družba, d. d., Verovškova 57, Ljubljana, Slovenija. Način i mjesto izdavanja lijeka Lijek se izdaje na recept, u ljekarni. TERAPIJSKE INDIKACIJE Ketoprofen pripada skupini protuupalnih lijekova koja se zove nesteroidni antireumatici (NSAR). Namijenjen je za otklanjanje i ublažavanje boli kod nekih bolnih sindroma i za liječenje upalnih, degenerativnih i metaboličkih reumatskih bolesti. Indikacije za uporabu tableta Ketonal forte su: Bol - posttraumatska bol (bol nakon ozljeda) - postoperativna bol - bolne mjesečnice - bol kod koštanih metastaza u bolesnika s neoplazmom Reumatske bolesti - reumatoidni artritis - seronegativni spondilartritis (ankilozantni spondilitis, psorijatični artritis, reaktivni artritis) giht, pseudogiht - artroza - izvanzglobni reumatizam (tendinitis, burzitis, upala ovojnice ramenog zgloba) KONTRAINDIKACIJE Primjena tableta Ketonal forte kontraindicirana je u bolesnika: - koji su preosjetljivi na ketoprofen ili na druge sastojke lijeka - koji su imali napadaje astme, urtikariju 111 reakcije preosjetljivosti nakon primjene - ketoprofena ili drugih nesteroidnih antireumatika ili salicilata (lijekovi za ublažavanje boli i snižavanje povišene temperature) - koji imaju teže oštećenje funkcije srca - za ublažavanje boli kod ugradnje premosnice (bypass) - koji imaju kroničnu dispepsiju (nelagoda i bol u gornjem dijelu trbušne šupljine) koji imaju aktivni ulkus želuca (čir na želucu) i dvanaesnika - koji su u prošlosti imali krvarenja iz probavnog sustava, ulceracije (čirevi želuca crijeva) ili perforacije (prsnuća stijenke želuca ili crijeva) - koji su imali krvarenja iz probavnog sustava, cerebrovaskularna (krvarenja u mozgu) druga krvarenja - sa sklonošću krvarenjima - koji imaju teško poremećenu funkciju bubrega ili jetre - koji imaju astmu ili rinitis (upala nosne sluznice). Primjena tableta Ketonal forte kontraindicirana je tijekom zadnja tri mjeseca trudnoće i u djece mlade od 15 godina starosti. Posavjetujte se s liječnikom ako niste sigurni da 11 smijete primjenjivati tablete Ketonal forte. ODGOVARAJUĆE MJERE OPREZA PRI UPORABI Molimo da pažljivo pročitate ovu uputu prije nego što primijenite lijek, čak i ako ste ga već koristili. Prije početka liječenja tabletama Ketonal forte svoga liječnika morate upoznati sa svim zdravstvenim tegobama koje ste imali iii ih imate kao i o tome da 11 ste na nešto alergični. Neželjeni učinci mogu se umanjiti primjenom najmanje učinkovite doze kroz najkraće moguće vrijeme. Potrebno je izbjegavati istovremenu uporabu Ketonala s drugim nesteroidnim protuupalnim lijekovima, uključujući selektivne inhibitore ciklooksigenaze. U starijih osoba postoji veća učestalost nuspojava, osobito krvarenja i perforacija (prsnuća) u probavnom sustavu, koje mogu imati smrtni ishod. Bolesnicima s poremećajima u probavnom sustavu preporučuje se poseban oprez kada se primjenjuju nesteroidni protuupalni tijekovi. Iznenadna prsnuća i k rvarenja mogu se javiti bez ikakvih znakova upozorenja. Takvi bolesnici bi trebali započeti liječenje s najnižom mogućom dozom. Ukoliko tijekom primjene Ketonala nastane krvarenje, stvaranje čira ili prsnuće u probavnom sustavu, bolesnik treba odmah prekinuti primjenu lijeka i o tome obavijestiti liječnika. Oprez je potreban u bolesnika koji istodobno primjenjuju druge lijekove koji mogu povećati rizik od nastanka čira ili krvarenja u probavnom sustavu, kao što su peroralni kortikosteroidi (hormoni nadbubrežne žlijezde), antikoagulansi (lijekovi za sprječavanje zgrušavanja krvi) (npr. varfarin), selektivni inhibitori ponovne pohrane serotonina (lijekovi za liječenje depresije ) ili antitrombotici (lijekovi za sprječavanje stvaranja krvnih ugrušaka) (npr. acetilsalicilna kiselina). Oprez je potreban u bolesnika koji su već bolovali od različitih oboljenja probavnog sustava (ulcerozni kolitis , Crohnova bolest ), zbog mogućeg pogoršanja bolesti. Ketoprofen treba davati s oprezom bolesnicima s neliječenom hipertenzijom (povišeni krvni tlak), zatajenjem srca, dokazanom ishemijskom bolešću srca, perifernom arterijskom bolešću i/ili cerebrovaskularnom bolešću (bolest krvnih žila u mozgu) ili drugim stanjima koja uzrokuju zadržavanje tekućine. Tijekom liječenja s nesteroidnim antireumaticima, preporučuje se češće mjerenje krvnog tlaka, osobito u bolesnika s bolestima srca i krvnih žila Prije početka dugotrajnog liječenja nesteroidnim protuupalnim lijekovima, oprez je potreban u bolesnika koji imaju povećani rizik za nastanak kardiovaskularnih bolesti (bolesti srca krvnih žila). To su bolesnici s hipertenzijom (povišeni krvni tlak), hiperlipidemijom (povišena razina masnoća u krvi), šećernom bolešću, pušači i sl. Neki nesteroidni protuupalni lijekovi (posebice u visokim dozama i kod dugotrajnog liječenja) mogu povećati rizik za nastanak srčanog ili moždanog udara. Nedostatak podataka ne isključuje mogućnost istog rizika kod primjene Ketonala. Ketoprofen može izazvati napadaj astme, pogotovo u osoba preosjetljivih na salicilate (lijekovi za ublažavanje boli i snižavanje povišene temperature) na nesteroidne protuupalne lijekove. U bolesnika s astmom praćenom kroničnim rinitisom (upala nosne sluznice), kroničnim sinusitisom (upala sinusa) i/ili nosnim polipima postoji veći rizik za nastanak alergijske reakcije (reakcija preosjetljivosti) nakon primjene acetilsalicilne kiseline (lijek za ublažavanje boli i snižavanje povišene temperature) i/iii nesteroidnih protuupalnih lijekova. Oprez je potreban u bolesnika koji imaju poremećaj rada jetre ili bubrega. Kao i kod svih dugotrajnih liječenja nesteroidnim antireumaticima, liječenje ketoprofenom zahtjeva praćenje krvne slike, jetrene i bubrežne funkcije, osobito u starijih bolesnika. Bolesnike sa zatajenjem jetre ili bubrega, bolesnike koji uzimaju diuretike (lijekovi koji potiču izlučivanje mokraće), bolesnike nakon velikih zahvata koji su uzrokovali hipovolemiju (smanjeni volumen krvi u cirkulaciji) i starije bolesnike treba pažljivo pratiti. Oprez je, također, potreban u bolesnika s poremećajem hemostaze (zaustavljanje krvarenja), hemofilijom (nasljedna bolest praćena sklonošću krvarenju), von Willebrandovom bolešću (nasljedna bolest poremećaja zgrušavanja krvi), teškom trombocitopenijom (smanjeni broj krvnih pločica) i u onih koji uzimaju antikoagulanse (lijekovi za sprječavanje zgrušavanja krvi) (npr. derivate kumarina i heparina). Ketoprofen treba primjenjivati s oprezom u alkoholičara. Vrlo rijetko su uz primjenu nesteroidnih antireumatika zabilježene ozbiljne kožne reakcije, ponekad sa smrtnim ishodom, kao npr. eksfolijativni dermatitis (upala s ljuštenjem kože), Stevens-Johnsonov sindrom (mjehuri na sluznici usta, ždrijela, spolovila i očne spojnice) toksična epidermalna nekroliza (teška kožna bolest sa stvaranjem mjehura). Najveći rizik od pojave ovih reakcija je na početku liječenja i to najčešće unutar prvog mjeseca primjene nesteroidnih antireumatika. Ukoliko se tijekom primjene Ketonala pojave kožni osip, oštećenja sluznice Hi drugi znakovi preosjetljivosti, primjenu lijeka treba odmah prekinuti. Kao i svi nesteroidni protuupalni lijekovi, ketoprofen može prikriti znakove zaraznih bolesti. Prije velikih kirurških zahvata treba prekinuti uzimanje lijeka. Primjena Ketonala ne preporučuje se ženama koje žele zatrudnjeti ili koje su na pretragama zbog neplodnosti, jer ketoprofen može smanjiti plodnost. Važna informacija o nekim sastojcima tablete Ketonal forte Tablete Ketonal forte sadržavaju laktozu i nisu prikladne za osobe s rijetkim nasljednim poremećajima poput nepodnošenja galaktoze, pomanjkanja Lappove laktaze ili glukoza/galaktoza malapsorpcijskog sindroma. Obavijestite svoga liječnika o svim tim stanjima. Molimo da se obratite liječniku i onda ako su se gornje navedene tvrdnje odnosile na vas bilo kada u prošlosti. INTERAKCIJE Obavijestite svoga liječnika ili ljekarnika ako uzimate ili ste nedavno uzimali bilo koji drugi lijek, pa i ako ste ga kupili bez recepta. Nemojte uzimati Ketonal zajedno s drugim nesteroidnim antireumaticima, salicilatima (lijekovi za ublažavanje boli i snižavanje povišene temperature), npr. acetilsalicilnom kiselinom ili neselektivnim inhibitorima ciklooksigenaze-2. Učinak antihipertenziva (lijekovi za liječenje visokog krvnog tlaka) i diuretika (Lijekovi koji potiču izlučivanje mokraće) može biti smanjen ako se uzimaju istodobno s ketoprofenom. Kod istodobne primjene nesteroidnih antireumatika i diuretika (lijekovi koji potiču izlučivanje mokraće) ili ACE-inhibitora (lijekovi za liječenje visokog krvnog tlaka i zatajenja srca) povećava se rizik od oštećenja funkcije bubrega. Učinak lijekova za liječenje epilepsije (padavica) ili šećerne bolesti može biti povećan ako se uzimaju istodobno s ketoprofenom. Zbog povećanog rizika od krvarenja, bolesnici koji istodobno uzimaju ketoprofen i antikoagulanse (lijekovi za sprječavanje zgrušavanja krvi), kortikosteroide (hormoni nadbubrežne žlijezde) ili selektivne inhibitore ponovne pohrane serotonina (lijekovi za liječenje depresije) zahtijevaju stalni liječnički nadzor. Ne preporučuje se istovremena primjena antikoagulansa (lijekovi za sprječavanje zgrušavanja krvi), sulfonamida (lijekovi za liječenje infekcija) ili hidantotna (lijek za liječenje padavice), jer je ponekad potrebno smanjiti njihovu dozu. Ako se istodobno s ketoprofenom uzimaju srčani glikozidi (lijekovi za jačanje snage srca), litij (lijek za liječenje nekih vrsta depresije), ciklosporin (lijek za smanjenje reakcije imunosnog sustava, kako bi se spriječilo odbacivanje presađenog organa ili koštane srži) ili metotreksat (lijek za liječenje zloćudnih bolesti) izlučivanje ovih lijekova može biti smanjeno, a njihov štetni učinak povećan. Učinak mifepristona (hormonski lijek protiv začeća) može biti smanjen ako se koristi istodobno s nesteroidnim antireumaticima. Nesteroidni antireumatici ne bi se smjeli uzimati još 8 do 12 dana nakon primjene mifepristona. Neki lijekovi kao što su: preparati kalija, diuretici (lijekovi koji potiču izlučivanje mokraće) koji štede kalij, ACE-inhibitori (lijekovi za liječenje visokog krvnog tlaka i zatajenja srca), inhibitori angiotenzina II (lijekovi za liječenje visokog krvnog tlaka i zatajenja srca), nesteroidni antireumatici, heparini (lijek za sprječavanje zgrušavanja krvi), ciklosporin (lijek za smanjenje reakcije imunosnog sustava, kako bi se spriječilo odbacivanje presađenog organa ili koštane srži), takrolimus (lijek koji djeluje na imunosni sustav) 111 trimetoprim (antimikrobni lijek) mogu povećati rizik nastanka hiperkalijemije (povišena razina kalija). Ne preporučuje se konzumiranje alkohola tijekom liječenja ketoprofenom. POSEBNA UPOZORENJA Prije nego što uzmete bilo koji lijek posavjetujte se sa svojim liječnikom ili ljekarnikom. Recite liječniku ako ste trudni (iii mislite da ste trudni) ili ako dojite. Nema podataka o sigurnosti primjene ketoprofena u trudnoći. Tijekom prvog i drugog tromjesečja trudnice smiju uzimati tablete Ketonal forte samo ako je očekivana korist liječenja veća od mogućeg rizika za plod. Primjena tableta Ketonal forte je kontraindicirana tijekom zadnja tri mjeseca trudnoće, jer može odgoditi porod, izazvati prerano zatvaranje ductus-a Botalli i plućnu hipertenziju novorođenčeta. Dojenje Prije nego što uzmete bilo koji lijek posavjetujte se sa svojim liječnikom ili ljekarnikom. Sigurnost primjene ketoprofena tijekom dojenja nije utvrđena, zbog čega se njegova primjena u dojilja ne preporučuje. Utjecaj na sposobnost upravljanja vozilima i strojevima Nesteroidni antireumatici rijetko mogu u preosjetljivih bolesnika uzrokovati omaglicu, vrtoglavicu, pospanost i zamagljeni vid. U tim slučajevima, bolesnici ne smiju upravljati vozilima niti rukovati strojevima. DOZIRANJE I PRIMJENA Tablete Ketonal forte se primjenjuju peroralno. Tablete Ketonal forte uzimajte točno kako vam je rekao liječnik. Ne mijenjajte doze i ne prekidajte liječenje bez prethodnog savjetovanja s vašim liječnikom. Liječnik će vam reći koliko dugo će trajati liječenje. Tabletu Ketonal forte treba progutati s čašom vode iti mlijeka. Tablete se mogu uzeti tijekom ili nakon obroka, ili s antacidima (lijekovi koji smanjuju lučenje želučane kiseline), jer smanjuju učestalost neželjenih učinaka ketoprofena na probavni sustav. Odrasli i djeca starija od 15 godina Uobičajeno doziranje je 1 tableta Ketonal forte jedanput ili dvaput na dan (100- 200 mg) ovisno o tjelesnoj masi bolesnika i o težini simptoma bolesti. Preporučena doza za liječenje reumatoidnog artritisa i artroze je 1 tableta Ketonal forte najviše dva puta na dan. Tablete i čepići mogu se kombinirati, na primjer: 1 tableta Ketonal forte (100 mg) ujutro i 1 čepić Ketonal (100 mg) uvečer. Ukupna dnevna doza ketoprofena ne smije biti veća od 200 mg. Treba pažljivo procijeniti omjer rizika i koristi liječenja ketoprofenom u dozi od 200 mg na dan, dok se veće doze ne preporučuju. Neželjeni učinci mogu se umanjiti primjenom najmanje učinkovite doze kroz najkraće moguće vrijeme. Ako vam se čini da je učinak lijeka prejak ili preslab, razgovarajte sa svojim liječnikom ljekarnikom. Stariji bolesnici Nesteroidne protuupalne lijekove treba primjenjivati s oprezom u starijih bolesnika zbog veće učestalosti nuspojava. Potrebno je primijeniti najmanju učinkovitu dozu i pratiti bolesnika tijekom prva 4 tjedna primjene lijeka zbog mogućnosti krvarenje iz probavnog sustava. Djeca Nema dovoljno podataka o doziranju u djece mlađe od 15 godina. PREDOZIRANJE Nikad ne smijete uzeti više tableta nego što vam je propisao liječnik. Ako ste uzeli previše tableta odjedanput, odmah se obratite liječniku. Liječniku pokažite preostale tablete u pakiranju. Prekomjerna doza može izazvati mučninu, povraćanje, epigastričnu bol (bol u području želuca), hematemezu (povraćanje krvi ), crnu stolicu, poremećaj svijesti, otežano disanje , konvulzije (grčeve), smanjenu bubrežnu funkciju i zatajenje bubrega Ako ste zaboravili uzeti lijek Ako ste zaboravili uzeti lijek, nemojte uzeti dvostruku dozu da biste nadoknadili propuštenu. Jednostavno nastavite uzimati lijek prema uobičajenom rasporedu. NUSPOJAVE Kao i svi lijekovi, tablete Ketonal forte mogu imati nuspojave. Nuspojave Ketonala obično su blage i prolazne. Najčešće nuspojave nesteroidnih antireumatika su nuspojave probavnog sustava. Mogu nastati: mučnina , povraćanje, zatvor , proljev , nadutost , grčevi i bol u želucu. Rijetko su zabilježene nuspojave kao što su melena (crna stolica), hematemeza (povraćanje krvi), ulcerozni stomatitis (upala i oštećenje sluznice usne šupljine), čir na želucu ili dvanaesniku, puknuće ili krvarenje iz probavnog sustava i gastritis (upalna bolest želuca). Druge blage nuspojave koje se rjeđe javljaju su glavobolja , omaglica, vrtoglavica, blaga zbunjenost, pospanost, otekline, promjene raspoloženja i nesanica U slučaju teže nuspojave, liječenje Ketonalom treba odmah prekinuti. Nuspojave mogu biti: vrio česte (> 10 %), česte (> 1 % i 0,1 % i 0,01 % i < 0,1 %) i vrio rijetke (< 0,01 %), uključujući pojedinačne slučajeve. Poremećaji srca i krvnih žila Često: edemi (otekline) Neki nesteroidni protuupalni lijekovi (posebice u visokim dozama i kod dugotrajnog liječenja) mogu povećati rizik za nastanak srčanog ili moždanog udara. Nedostatak podataka ne isključuje mogućnost istog rizika kod primjene ketoprofena. Poremećaji krvi i limfnog sustava Manje često: anemija (smanjeni broj crvenih krvnih stanica/hemoglobina), hemoliza (raspadanje crvenih krvnih stanica), purpura (gusto, točkasto krvarenje u koži), trombocitopenija (smanjeni broj krvnih pločica), agranulocitoza (gubitak granulocita) Ketoprofen u visokim dozama može smanjiti agregaciju (nakupljanje) trombocita (krvne pločice), produžiti vrijeme krvarenja, izazvati krvarenja iz nosa i pojavu modrica. Poremećaji središnjeg živčanog sustava Nuspojave mogu biti: vrio česte (> 10 %), česte (> 1 % i 0,1 % i 0,01 % i < 0,1 %) i vrio rijetke (< 0,01 %), uključujući pojedinačne slučajeve. Poremećaji središnjeg živčanog sustava često: glavobolja, astenija (gubitak snage), slabost, umor , omaglica, vrtoglavica, parestezije (umrtvljenost ili trnci u prstima na rukama i nogama), depresija , nervoza, pospanost, noćne more Rijetko: delirij (poremećenost svijesti) s vidnim i slušnim priviđanjima, dezorijentacija (poremećaj orijentacije), smetnje u govoru Vrlo rijetko: moždani pseudotumor (povećanje krvnog tlaka u glavi) – (jedan slučaj) Poremećaji dišnog sustava, prsnog koša Manje često: hemoptiza (iskašljavanje krvi ), dispneja (otežano disanje), faringitis (upala ždrijela), rinitis (upala nosne sluznice), bronhospazam (suženje dušnica), edem tarinksa (otok grkljana) znaci reakcije preosjetljivosti Rijetko: napadaj astme Poremećaji probavnog sustava Vrlo često: dispepsija (nelagoda i bol u gornjem dijelu trbušne šupljine) Često: mučnina, boi u trbuhu, proljev, zatvor, nadutost, anoreksija (gubitak teka), povraćanje, stomatitis (upala sluznice usne šupljine) Vrio rijetko: gastritis (upalna bolest želuca), intestinalna perforacija (puknuće crijeva), pogoršanje ulceroznog kolitisa (upala i oštećenje sluznice debelog crijeva) ili Crohnove bolesti (teška upalna bolest crijeva), enteropatija (bolest crijeva) s perforacijom (prsnuće), ulceracijom (nastajanje čira) ili strikturom (suženje crijeva) Enteropatija može biti praćena blagim krvarenjem i gubitkom bjelanjčevina. Zabilježen je slučaj (starija žena) perforacije kolona (prsnuće debelog crijeva). čir na želucu, perforacija (prsnuće) ili krvarenje iz probavnog sustava, ponekad su sa smrtnim ishodom, osobito u starijih osoba. Poremećaj funkcije jetre, žučnjaka i žučnih vodova Vrio često: granično povećane vrijednosti jetrenih testova Manje često: značajno povećanje vrijednosti jetrenih enzima Vrlo rijetko: poremećaj funkcije jetre sa žuticom i hepatitisom (upala jetre) Poremećaji bubrega i mokraćnog sustava Vrlo rijetko: akutno zatajenje bubrega , intersticijski nefritis (upala bubrega), nefrotski sindrom, akutni pijelonefritis (upala bubrega i bubrežne nakapnice) Poremećaji reprodukcijskog sustava Manje često: menometroragija (poremećaj krvarenja tijekom ili između menstruacijskih ciklusa) Poremećaji kože i potkožnog tkiva Često: osip Manje često: alopecija (gubitak kose ), ekcem, crvenilo kože, urtikarija , eksfolijativni dermatitis (upala kože s ljuštenjem) Rijetko: fotoosjetljivost (preosjetljivost na svjetlost), fotodermatitis (kožne promjene izazvane preosjetljivošću na svjetlost) Vrlo rijetko: bulozne (mjehuraste) kožne promjene uključujući Stevens-Johnsonov sindrom (mjehuri na sluznici usta, ždrijela, spolovila i očne spojnice) i toksičnu epidermalnu nekrolizu (teška kožna bolest sa stvaranjem mjehura). Poremećaji funkcije oka često: smetnje vida Vrio rijetko: konjunktivitis (upala očne spojnice) (jedan slučaj) Poremećaji funkcije uha i labirinta Ostale nuspojave Rijetko: alergijske reakcije (preosjetljivost) ili anafilaksija (teška reakcija preosjetljivosti). Prekinite primjenu Ketonala i odmah se javite liječniku ako: - teško dišete - imate bol u prsima - imate promjene srčanog ritma - imate osip, urtikariju - postanete preosjetljivi na svjetlost — primijetite oticanje gležnjeva, nogu ili lica — primijetite neuobičajena krvarenja ili modrice na koži - imate žutu kožu i žute bjeloočnice - mokrite manje nego inače - imate jake bolove u trbuhu ili povraćate krv - imate krvavu, crnu stolicu - imate neobjašnjivo povišenje tjelesne temperature ili bolove u grlu - imate povišeni krvni tlak. Nemojte se zabrinjavati zbog gore navedenih nuspojava jer većina bolesnika uzima ketoprofen bez ikakvih problema; ozbiljne nuspojave su vrlo rijetke. UVJETI ČUVANJA Lijek treba čuvati izvan dohvata djece. Lijek se čuva pri temperaturi do 25° C. Lijek se čuva u originalnoj ambalaži. Napomena: Ove upute o proizvodima samo su ilustrativnog karaktera. Ukoliko trebate savjet u vezi korištenja lijeka obratite se liječniku ili ljekarniku.