Rectogesic 4 mg/g Rectal Ointment indicated in Adults for Relief of Pain associated with Chronic Anal Fissure

Rectogesic 4 mg/g Rectal Ointment is indicated in adults for relief of pain associated with chronic anal fissure.

In the clinical development of the drug, a modest effect has been shown on improvements in average daily pain intensity (see Section 5.1).

Route of administration: rectal use

Adults:

A finger covering, such as cling film or a finger cot, may be placed on the finger to be used to apply the ointment. (Finger cots to be obtained separately from local pharmacy or surgical supplies retailer or cling film from local store.) The finger is placed along side a 2.5cm dosing line which is provided on the outside carton in which Rectogesic is supplied, and a strip of ointment the length of the line is expressed onto the end of the finger by gently squeezing the tube. The amount of ointment expressed is approximately 375 mg (1.5 mg GTN). The covered finger is then gently inserted into the anal canal to the distal interphalangeal joint of the finger and applied circumferentially to the anal canal.

The dose delivered from the 4 mg/g ointment is 1.5 mg glyceryl trinitrate. The dose is to be applied intra-anally every twelve hours. Treatment may be continued until the pain abates, up to a maximum of 8 weeks.

Rectogesic should be used following conservative treatment failure for acute symptoms of anal fissure.

Elderly (over 65 years):

No specific information concerning the usage of Rectogesic in the elderly is available

Patients with Hepatic or Renal Impairment

No specific information concerning the usage of Rectogesic in patients with hepatic or renal impairment is available

Children and Adolescents:

Rectogesic is not recommended for use in children and adolescents below 18 years of age due to a lack of data on safety and efficacy.

Hypersensitivity to the active substance “glyceryl trinitrate” or to any of the excipients listed in section 6.1 or to other organic nitrates.

Concomitant treatment with phosphodiesterase type 5 (PDE5) inhibitors e.g sildenafil citrate, tadalafil, vardenafil and other organic nitrates with nitric oxide (NO) donors, such as other long-acting GTN products, isosorbide dinitrate and amyl or butyl-nitrite.

Postural hypotension, hypotension or uncorrected hypovolaemia as the use of glyceryl trinitrate in such states could produce severe hypotension or shock.

Increased intracranial pressure (e.g. head trauma or cerebral haemorrhage) or inadequate cerebral circulation.

Migraine or recurrent headache.

Aortic or mitral stenosis.

Hypertrophic obstructive cardiomyopathy.

Constrictive pericarditis or pericardial tamponade.

Marked anaemia.

Closed-angle glaucoma.

The risk/benefit ratio of Rectogesic has to be established on an individual basis. In some patients, following treatment with Rectogesic, severe headache can occur. In some cases re-evaluation of the correct dosing is suggested. In patients where the risk benefit ratio is deemed to be negative, treatment with Rectogesic should be withdrawn under the guidance of a physician and other therapeutic or surgical interventions should be initiated.

Rectogesic should be used with caution in patients who have severe hepatic or renal disease.

Excessive hypotension, especially for prolonged periods of time, must be avoided because of possible deleterious effects on the brain, heart, liver and kidney from poor perfusion and the attendant risk of ischaemia, thrombosis and altered function of these organs. Patients should be advised to change position slowly when changing from lying or sitting to upright to minimize postural hypotension. This advice is particularly important for those patients with low blood volume and under diuretic treatment. Paradoxical bradycardia and increased angina pectoris may accompany glyceryl trinitrate-induced hypotension. The elderly may be more susceptible to the development of postural hypotension, particularly on sudden rising. No specific information concerning the usage of Rectogesic in the elderly is available.

Alcohol may enhance the hypotensive effects of glyceryl trinitrate.

If the physician elects to use glyceryl trinitrate ointment for patients with cardiac disorders e.g. acute myocardial infarction or congestive heart failure, careful clinical and haemodynamic monitoring must be used to avoid the potential hazards of hypotension and tachycardia.

If bleeding associated with haemorrhoids increases, treatment should be stopped.

This formulation contains propylene glycol and lanolin which may cause skin irritations and skin reactions (e.g. contact dermatitis).

If anal pain persists, differential diagnosis may be required to exclude other causes of the pain.

Glyceryl trinitrate can interfere with the measurement of catecholamines and vanilmandelic acid in urine as it increases the excretion of these substances.

Concomitant treatment with a number of other medicinal products should be handled with caution. Please refer to section 4.5 for specific information.

Concomitant treatment with other vasodilators, calcium channel blockers, ACE inhibitors, beta blockers, diuretics, anti-hypertensives, tricyclic anti-depressants and major tranquillisers, as well as the consumption of alcohol, may potentiate the blood pressure lowering effects of Rectogesic. Therefore, concomitant treatment with these medications should be carefully considered before treatment with Rectogesic is initiated.

The hypotensive effect of organic nitrates are potentiated by concurrent administration of phosphodiesterase type 5 (PDE5) inhibitors, e.g. sildenafil, tadalafil and vardenafil (see Section 4.3).

Rectogesic is contraindicated for concomitant treatment with, nitric oxide (NO) donors such as isosorbide dinitrate and amyl or butyl-nitrite (see Section 4.3).

Acetyl cysteine may potentiate the vasodilatory effects of glyceryl trinitrate.

Concomitant treatment of intravenous glyceryl trinitrate with intravenous heparin leads to a decrease in heparin efficacy. Close monitoring of blood coagulation parameters is necessary and the dose of heparin has to be adapted accordingly. After withdrawal of Rectogesic there may be an abrupt increase in PTT. In this case reduction of heparin dosage may be necessary.

Concurrent administration of intravenous glyceryl trinitrate and alteplase may cause a reduction of the thrombolytic activity of alteplase.

Co-administration of Rectogesic with dihydroergotamine may increase the bioavailability of dihydroergotamine and lead to coronary vasoconstriction. The possibility that the ingestion of acetylsalicylic acid and non-steroidal anti-inflammatory drugs might alter the therapeutic response to Rectogesic cannot be excluded.

Fertility: There are no data available on the effect of Rectogesic on fertility in humans. Studies in rats suggest no particular hazard under recommended conditions of use 

Pregnancy: There are no adequate data from the use of glyceryl trinitrate in pregnant women. Animal studies are inconclusive with respect to effects on pregnancy embryonal/foetal parturition and postnatal development (see Section 5.3). Rectogesic should not be used during pregnancy.

Lactation: It is not known whether glyceryl trinitrate is excreted in human milk. Due to the potential harmful effects on the breast fed child (see Section 5.3), the use of Rectogesic is not recommended during breast feeding.

No studies on the effect on the ability to drive and use machines have been performed with Rectogesic. Rectogesic may cause dizziness, light-headedness, blurred vision, headache or tiredness in some patients, especially on first use. Patients should be cautioned about driving or operating machinery while using Rectogesic.