Combodex

/ Dexcel

For orl administration and short term use only.
The patient should consult a doctor if the symptoms persist or worsen or if the product is required for more than 3 days.
Undesirable effects may be minimised by using the lowest effective dose for the shortest duration necessary to control symptoms.
Adults and Children over 12 years: The usual dosage is one to two caplets taken every six hours, as required, up to a maximum of eight caplets in 24 hours.
Children under 12 years: This product is not recommended for children under 12 years.
Elderly: No special dosage modifications are required. The elderly are at increased risk of the serious consequences of adverse reactions. If an NSAID is considered necessary, the lowest effective dose should be used for the shortest possible duration. The patient should be monitored regularly for gastrointestinal bleeding during NSAID therapy.
Patients with renal/hepatic impairment: No special dosage adjustments are required.
Method of administration: This product is recommended to be taken with or straight after food with a full glass of water.

Temporary relief of pain associated with: headache, migraine headache, tension headache, sinus pain, toothache, dental procedures, backache, sore throat, arthritis, tennis elbow, period pain, muscular pain, rheumatic pain, aches and pains associated with colds and flu. Reduces fever.

* Hypersensitivity reaction to paracetamol, ibuprofen, other NSAIDs or to any of the excipients.
* Active alcoholism as chronic excessive alcohol ingestion may predispose patients to hepatotoxicity (due to the paracetamol component).
* Experienced asthma, urticaria, or allergic-type reactions after taking acetylsalicylic acid or other NSAIDs.
* Active or history of gastrointestinal bleeding or peptic ulceration, including that associated with NSAIDs.
* Severe heart failure (NYHA Class IV), hepatic failure or renal failure.
* Cerebrovascular or other active bleeding.
* Blood-formation disturbances.
* During the third trimester of pregnancy.
This product should not be taken with other products containing paracetamol, ibuprofen, acetylsalicylic acid, salicylates, cyclo-oxygenase-2 (COX-2) specific inhibitors or with any other anti-inflammatory medicines unless under a doctor’s instruction.

A doctor should be consulted if the symptoms persist or worsen or if the product is required for more than 3 days.
Hepatic Impairment: The use of paracetamol at higher than recommended doses can lead to hepatotoxicity and even hepatic failure and death. Also, patients with impaired liver function or a history of liver disease, or who are on long term ibuprofen therapy or paracetamol treatment should have hepatic function monitored at regular intervals, as ibuprofen has been reported to have a minor and transient effect on liver enzymes.
Severe hepatic reactions, including jaundice and cases of fatal hepatitis, though rare, have been reported with ibuprofen as with other NSAIDs. If abnormal liver tests persist or worsen, or if clinical signs and symptoms consistent with liver disease develop, or if systemic manifestations occur (e.g. eosinophilia, rash, etc.), ibuprofen should be discontinued. Both active drugs have been reported to cause hepatotoxicity and even hepatic failure, especially paracetamol. Patients who regularly consume alcohol in excess of recommended amounts should not take this medicine.
Dose reduction is recommended in patients showing signs of worsening hepatic function. Treatment should be stopped in those patients who develop severe liver failure.
Renal Impairment: Paracetamol can be used in patients with chronic renal disease without dosage adjustment. There is minimal risk of paracetamol toxicity in patients with moderate to severe renal failure. However, for the ibuprofen component of this product – caution should be used when initiating treatment with ibuprofen in patients with dehydration. The two major metabolites of ibuprofen are excreted mainly in the urine and impairment of renal function may result in their accumulation. The significance of this is unknown. NSAIDs have been reported to cause nephrotoxicity in various forms: interstitial nephritis, nephritic syndrome and renal failure. Renal impairment from ibuprofen use is usually reversible. In patients with renal, cardiac or hepatic impairment, those taking diuretics and ACE Inhibitors, and the elderly, caution is required since the use of nonsteroidal anti-inflammatory drugs may result in deterioration of renal function. The dose should be kept as low as possible and renal function should be monitored in these patients. Treatment should be stopped in those patients who develop severe renal failure.
Combination use of ACE inhibitors or angiotensin receptor antagonists, anti-inflammatory drugs and thiazide diuretics: The use of an ACE inhibiting drug (ACE-inhibitor or angiotensin receptor antagonist), an anti-inflammatory drug (NSAID or COX-2 inhibitor) and thiazide diuretic at the same time increases the risk of renal impairment. This includes use in fixed-combination products containing more than one class of drug. Combined use of these medications should be accompanied by increased monitoring of serum creatinine, particularly at the institution of the combination. The combination of drugs from these three classes should be used with caution particularly in elderly patients or those with pre-existing renal impairment.
Elderly: No adjustment in labelled dosage is necessary for older patients who require paracetamol therapy. Those who require therapy for longer than 10 days should consult their physician for condition monitoring; however, no reduction in recommended dosage is necessary. However, caution should be taken with regard to the use of ibuprofen as it should not be taken by adults over the age of 65 without consideration of co-morbidities and co-medications because of an increased risk of adverse effects, in particular heart failure, gastrointestinal ulceration and renal impairment.
Haematological Effects: Blood dyscrasias have been rarely reported. Patients on long-term therapy with ibuprofen should have regular haematological monitoring.
Coagulation Defects: Like other NSAIDs, ibuprofen can inhibit platelet aggregation. Ibuprofen has been shown to prolong bleeding time (but within the normal range), in normal subjects. Because this prolonged bleeding effect may be exaggerated in patients with underlying haemostatic defects, products containing ibuprofen should be used with caution in persons with intrinsic coagulation defects and those on anti-coagulation therapy.
Gastrointestinal Events: Upper gastro-intestinal ulcers, gross bleeding or perforation have been described with NSAIDs. The risks increase with dose and duration of treatment, and are more common in patients over the age of 65 years. Some patients will experience dyspepsia, heartburn, nausea, stomach pain or diarrhoea. These risks are minimal when this product is used at the prescribed dose for a few days. Products containing ibuprofen should be used with caution and at the lowest effective dose for the shortest duration, in patients with a history of gastrointestinal haemorrhage or ulcer since their condition may be exacerbated. Due to the ibuprofen component should be given with care to patients with a history of GI disease (ulcerative colitis, Crohn’s disease) as well as in patients with porphyria and varicella. This product should be discontinued if there is any evidence of gastrointestinal bleeding. The concurrent use of acetylsalicylic acid and NSAIDs also increases the risk of serious gastrointestinal adverse events.
Cardiovascular Thrombotic Events: Clinical studies suggest that use of ibuprofen, particularly at a high dose (2400 mg/day) may be associated with a small increased risk of arterial thrombotic events (for example myocardial infarction or stroke). Overall, epidemiological studies do not suggest that low dose ibuprofen (e.g. ≤ 1200 mg/day) is associated with an increased risk of arterial thrombotic events. Patients with uncontrolled hypertension, congestive heart failure (NYHA II-III), established ischaemic heart disease, peripheral arterial disease, and/or cerebrovascular disease should only be treated with ibuprofen after careful consideration and high doses (2400 mg/day) should be avoided. Careful consideration should also be exercised before initiating long-term treatment of patients with risk factors for cardiovascular events (e.g. hypertension, hyperlipidaemia, diabetes mellitus, smoking), particularly if high doses of ibuprofen (2400 mg/day) are required. Patients with cardiovascular disease or cardiovascular risk factors may also be at greater risk. To minimize the potential risk of an adverse cardiovascular event in patients taking an NSAID, especially in those with cardiovascular risk factors, the lowest effective dose should be used for the shortest possible duration. There is no consistent evidence that the concurrent use of acetylsalicylic acid mitigates the possible increased risk of serious cardiovascular thrombotic events associated with NSAIDs use.
Hypertension: NSAIDs may lead to onset of new hypertension or worsening of pre-existing hypertension and patients taking antihypertensive medicines with NSAIDs may have an impaired anti-hypertensive response. Caution is advised when prescribing NSAIDs to patients with hypertension. Blood pressure should be monitored closely during initiation of NSAID treatment and at regular intervals thereafter.
Heart failure: Fluid retention and oedema have been observed in some patients taking NSAIDs; therefore caution is advised in patients with fluid retention or heart failure.
Severe Skin Reactions: NSAIDs may very rarely cause serious cutaneous adverse events such as exfoliative dermatitis, toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS), which can be fatal and occur without warning. These serious adverse events are idiosyncratic and are independent of dose or duration of use. . Acute generalized exanthematous pustulosis (AGEP) has been reported in relation to ibuprofen containing products. Patients should be advised of the signs and symptoms of serious skin reactions and to consult their doctor at the first appearance of a skin rash or any other sign of hypersensitivity.
Respiratory disorders: In patients suffering from, or with a history of, bronchial asthma or allergic disease, NSAIDs have been reported to precipitate bronchospasm.
Ophthalmological effects: Adverse ophthalmological effects have been observed with NSAIDs; accordingly, patients who develop visual disturbances during treatment with products containing ibuprofen should have an ophthalmological examination.
Aseptic Meningitis: For products containing ibuprofen aseptic meningitis has been reported only rarely, usually but not always in patients with systemic lupus erythematosus (SLE) or other connective tissue disorders.
Potential Laboratory Test Interferences: Using current analytical systems, paracetamol does not cause interference with laboratory assays. However, there are certain methods with which the possibility of laboratory interference exists, as described below:
Urine Tests: Paracetamol in therapeutic doses may interfere with the determination of 5-hydroxyindoleacetic acid (5HIAA), causing false-positive results. False determinations may be eliminated by avoiding paracetamol ingestion several hours before and during the collection of the urine specimen.
Masking Signs of Infection: This product can mask symptoms of infection, which may lead to delayed initiation of appropriate treatment and thereby worsening the outcome of the infection.
Flucloxacillin: Caution is advised if paracetamol is administered concomitantly with flucloxacillin due to increased risk of high anion gap metabolic acidosis (HAGMA), particularly in patients with severe renal impairment, sepsis, malnutrition and other sources of glutathione deficiency (e.g. chronic alcoholism), as well as those using maximum daily doses of paracetamol. Close monitoring, including measurement of urinary 5- oxoproline, is recommended.
Special Precautions: In order to avoid exacerbation of disease or adrenal insufficiency, patients who have been on prolonged corticosteroid therapy should have their therapy tapered slowly rather than discontinued abruptly when products containing ibuprofen are added to the treatment program.
See prescribing information for full details.

Common: Oedema, fluid retention; fluid retention generally responds promptly to discontinuation of the drug, Tinnitus (for medicines containing ibuprofen), Abdominal pain, diarrhoea, dyspepsia, nausea, stomach discomfort and vomiting, Alanine aminotransferase increased, gammaglutamyl transferase increased and liver function tests abnormal with paracetamol, Blood creatinine increased and blood urea increased, Dizziness, headache, nervousness, Rash (including maculopapular type), pruritus.
See prescribing information for full details.

The following interactions of paracetamol with other medicines have been noted:
– anticoagulant drugs (warfarin) – dosage may require reduction if paracetamol and anticoagulants are taken for a prolonged period of time.
– paracetamol absorption is increased by substances that increase gastric emptying, e.g. metoclopramide.
– paracetamol absorption is decreased by substances that decrease gastric emptying, e.g. propantheline, antidepressants with anticholinergic properties, and narcotic analgesics.
– paracetamol may increase chloramphenicol plasma concentrations.
– the risk of paracetamol toxicity may be increased in patients receiving other potentially hepatotoxic drugs or drugs that induce liver microsomal enzymes such as alcohol and anticonvulsant agents.
– paracetamol excretion may be affected and plasma concentrations altered when given with probenecid.
– cholestyramine reduces the absorption of paracetamol if given within 1 hour of paracetamol.
– Severe hepatotoxicity at therapeutic doses or moderate overdoses of paracetamol has been reported in patients receiving isoniazid alone or with other drugs for tuberculosis.
– Severe hepatotoxicity has occurred after use of paracetamol in a patient taking zidovudine and co-trimoxazole.
– Caution should be taken when paracetamol is used concomitantly with flucloxacillin as concurrent intake has been associated with high anion gap metabolic acidosis, especially in patients with risks factors
The following interactions of ibuprofen with other medicines have been noted:
– anticoagulants, including warfarin – ibuprofen interferes with the stability of INR and may increase risk of severe bleeding and sometimes fatal haemorrhage, especially from the gastrointestinal tract. Ibuprofen should only be used in patients taking warfarin if absolutely necessary and they must be closely monitored.
– Ibuprofen may decrease renal clearance and increase plasma concentration of lithium.
– Ibuprofen may reduce the anti-hypertensive effect of ACE inhibitors, beta-blockers and diuretics and may cause natriuresis and hyperkalemia in patients under these treatments.
– Ibuprofen reduces methotrexate clearance.
– Ibuprofen may increase plasma levels of cardiac glycosides.
– Ibuprofen may increase the risk of gastrointestinal bleeding especially if taken with corticosteroids.
– Ibuprofen may prolong bleeding time in patients treated with zidovudine.
– Ibuprofen may also interact with probenecid, antidiabetic medicines and phenytoin.
– Ibuprofen may also interact with tacrolimus, ciclosporin, sulphonylureas and quinolone antibiotics.
– Selective serotonin re-uptake inhibitors (SSRIs) and NSAIDs each entail an increased risk of bleeding, e.g. from the gastrointestinal tract. This risk is increased by combination therapy. The mechanism may possibly be linked to reduced uptake of serotonin in the platelets.
– Mifepristone: A decrease of the efficacy of the medicinal product can theoretically occur due to the antiprostaglandin properties of NSAIDs including acetylsalicylic acid. Limited evidence.
Acetylsalicylic acid:
Concomitant administration of ibuprofen and acetylsalicylic acid is not generally recommended because of the potential of increased adverse effects. Experimental data suggest that ibuprofen may competitively inhibit the effect of low dose acetylsalicylic acid on platelet aggregation when they are dosed concomitantly. Although there are uncertainties regarding extrapolation of these data to the clinical situation, the possibility that regular, long-term use of ibuprofen may reduce the cardioprotective effect of low-dose acetylsalicylic acid cannot be excluded. No clinically relevant effect is considered to be likely for occasional ibuprofen use.
This product may interfere with some medicines. These include:
– warfarin, a medicine used to prevent blood clots
– medicines to treat epilepsy or fits
– chloramphenicol, an antibiotic used to treat ear and eye infections
– probenecid, a medicine used to treat gout
– zidovudine, a medicine used to treat HIV (the virus that causes AIDs)
– medicines used to treat tuberculosis such as isoniazid
– acetylsalicylic acid, salicylates or other NSAID medicines
– medicines to treat high blood pressure or other heart conditions
– diuretics, also called fluid tablets
– lithium, a medicine used to treat some types of depression
– methotrexate, a medicine used to treat arthritis and some types of cancer
– corticosteroids, such as prednisone, cortisone
The above medicines may be affected by this product or may affect how well this product works.
See prescribing information for full details.

Pregnancy: There is no experience of use of this product in humans during pregnancy.
For Ibuprofen
From the 20th week of pregnancy onward, this product use may cause oligohydramnios resulting from foetal renal dysfunction. This may occur shortly after treatment initiation and is usually reversible upon discontinuation. In addition, there have been reports of ductus arteriosus constriction following treatment in the second trimester, most of which resolved after treatment cessation. Therefore, during the first and second trimester of pregnancy, this medical product should not be given unless clearly necessary.
Consequently, this product is contraindicated during the third trimester of pregnancy.
For Paracetamol
A large amount of data on pregnant women using paracetamol indicate neither
malformative, nor feto/neonatal toxicity. If clinically needed, paracetamol can be used during pregnancy however it should be used at the lowest effective dose for the shortest possible time and at the lowest possible frequency.
Lactation: Paracetamol is excreted in breast milk but not in a clinically significant amount and available published data do not contraindicate breastfeeding.

Symptoms
Paracetamol: Liver injury and even failure can occur following paracetamol overdose. Symptoms of paracetamol overdose in the first 24 hours are pallor, nausea, vomiting, anorexia and abdominal pain. Liver damage may become apparent 12 to 48 hours after ingestion. Abnormalities of glucose metabolism and metabolic acidosis may occur. In severe poisoning, hepatic failure may proceed to encephalopathy, coma and death. Acute renal failure with acute tubular necrosis may develop in the absence of severe liver damage. Cardiac arrhythmias have been reported. Liver damage is possible in adults who have taken 10 g or more of paracetamol, due to excess quantities of a toxic metabolite.
Ibuprofen: Symptoms include nausea, abdominal pain and vomiting, dizziness, convulsion and rarely, loss of consciousness. Clinical features of overdose with ibuprofen which may result are depression of the central nervous system and the respiratory system. In serious poisoning, metabolic acidosis may occur.
Treatment
Paracetamol: Prompt treatment is essential in the management of paracetamol overdose even when there are no obvious symptoms, because of the risks of liver injury, which presents after some hours or even days delay. Medical treatment is advised, without delay in any patient who has ingested 7.5 g or more of paracetamol in the preceding 4 hours. Gastric lavage should be considered. Specific therapy to reverse liver injury with an antidote such as acetylcysteine (intravenous) or methionine (oral) should be instituted as soon as possible. Acetylcysteine is most effective when administered during the first 8 hours following ingestion of the overdose and the effect diminishes progressively between 8 and 16 hours. It used to be believed that starting treatment more than 15 hours after overdose was of no benefit and might possibly aggravate the risk of hepatic encephalopathy. However, late administration has now been shown to be safe, and studies of patients treated up to 36 hours after ingestion suggest that beneficial results may be obtained beyond 15 hours. Furthermore, administration of intravenous acetylcysteine to patients who have already developed fulminant hepatic failure has been shown to reduce morbidity and mortality. An initial dose of 150 mg/kg of acetylcysteine in 200 mL 5% glucose is given intravenously over 15 minutes, followed by an I.V. infusion of 50 mg/kg in 500 mL 5% glucose over 4 hours and then 100 mg/kg in 1 litre 5% glucose over 16 hours. The volume of I.V. fluids should be modified for children. Methionine is given orally as 2.5 g every 4 hours up to 10 g. Methionine treatment must be started within 10 hours after ingestion of paracetamol; otherwise it will be ineffective and may exacerbate liver damage. Evidence of serious symptoms may not become apparent until 4 or 5 days following overdose and patients should be carefully observed for an extended period.
Ibuprofen: In cases of acute overdose, the stomach should be emptied by vomiting or lavage, though little drug will likely be recovered if more than an hour has elapsed since ingestion. Because the drug is acidic and is excreted in the urine, it is theoretically beneficial to administer alkali and induce diuresis. In addition to supportive measures, the use of oral activated charcoal may help to reduce the absorption and reabsorption of ibuprofen tablets.

Contains lactose.
Should be administrated with a full glass of water, immediately after a meal.
See prescribing information for full details.