Myoril Plus

Uses

Ketoprofen is used for musculoskeletal and joint disorders such as ankylosing spondylitis, osteoarthritis, and rheumatoid arthritis, in periarticular disorders such as bursitis and tendinitis, in mild to moderate pain such as dysmenorrhoea or postoperative pain, and in other painful and inflammatory conditions such as acute gout or soft tissue disorders.

Ketoprofen is used for symptomatic relief of mild to moderate pain, such as postoperative (including that associated with dental surgery) postpartum and orthopedic (including musculoskeletal strains or sprains) pain and visceral pain associated with cancer.

Ketoprofen IM injection is used for management of acute exacerbations of: Rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, periarticular conditions such as fibrositis, bursitis, capsulitis, tendinitis, and tenosynovitis, low back pain of musculoskeletal origin, sciatica, other musculoskeletal conditions, acute gout and control of pain and inflammation following orthopaedic surgery.

Ketoprofen 2.5% Gel is an anti-inflammatory and analgesic preparation to be applied topically to the painful area. It is used for a short-term treatment for traumatic lessions (sprains, tendinitis, edema, bruises) and pain.

Thiocolchicoside is a semi-synthetic colchicine derivative used as an analgesic and anti-inflammatory.

Thiocolchicoside is a skeletal muscle-relaxant drug used in the treatment of orthopedic, traumatic and rheumatologic disorders . It is indicated as an adjuvant drug in the treatment of painful muscle contractures and is indicated in acute spinal pathology, for adults and adolescents 16 years of age and older . Recent studies have examined its effect on muscle tone, stiffness, contractures, and soreness experienced by athletes during sporting competitions .

Myoril Plus is also used to associated treatment for these conditions: Ankylosing Spondylitis (AS), Migraine, Osteoarthritis (OA), Pain, Postpartum pain, Primary Dysmenorrhoea, Rheumatoid ArthritisBack Pain, Acute, Chronic Back Pain, Extra-Articular Rheumatism, Muscle Inflammation, Muscle Spasms, Musculoskeletal Pain, Nonspecific Pain Post Traumatic Injury, Osteoarthritis (OA), Pain, Post Surgical Pain, Post-traumatic pain, Postoperative pain, Rheumatoid Arthritis, Soreness, Muscle, Spasms, Spinal pain, Vertebral column pain, Inflammation localized, Localized pain, Mild to moderate pain, Musculoskeletal spasms

How Myoril Plus works

The anti-inflammatory effects of ketoprofen are believed to be due to inhibition cylooxygenase-2 (COX-2), an enzyme involved in prostaglandin synthesis via the arachidonic acid pathway. This results in decreased levels of prostaglandins that mediate pain, fever and inflammation. Ketoprofen is a non-specific cyclooxygenase inhibitor and inhibition of COX-1 is thought to confer some of its side effects, such as GI upset and ulceration. Ketoprofen is thought to have anti-bradykinin activity, as well as lysosomal membrane-stabilizing action. Antipyretic effects may be due to action on the hypothalamus, resulting in an increased peripheral blood flow, vasodilation, and subsequent heat dissipation.

Thiocolchicoside, is a synthetic sulfur derivative of colchicoside, a naturally occurring glucoside contained in the Colchicum autumnale plant. Thiocolchicoside has a selective and potent affinity for g-aminobutyric acid A (GABA-A) receptors and acts on muscular contractures by activating the GABA inhibitory pathways thereby behaving as a potent muscle relaxant . Gamma-aminobutyric acid (GABA) is the main inhibitory neurotransmitter in the human cortex . GABAergic neurons are involved in myorelaxation, anxiolytic treatment, sedation, and anesthetics. GABA can also modulate heart rate and blood pressure.

It also has an affinity for the inhibitory glycine receptors (i.e., have glycomimetic and GABA mimetic activity), therefore acts as a muscle relaxant. Glycine is an inhibitory neurotransmitter and acts as an allosteric regulator of NMDA (N-methyl-D-aspartate) receptors. It is involved in the processing of motor and sensory data, thereby regulating movement, vision, and audition. Inhibitory neurotransmitter in spinal cord, allosteric regulator of NMDA receptors .

In one study, thiocolchicoside inhibited the function of recombinant human strychnine-sensitive glycine receptors composed of the alpha1 subunit with a potency (median inhibitory concentration of 47 microM) lower than that apparent with recombinant GABA(A) receptors. The drug also inhibited the function of human nicotinic acetylcholine receptors made of the alpha4 and beta2 subunits, however, this effect was partial and moreover only apparent at high concentrations. Thiocolchicoside demonstrated no effect on the function of 5-HT(3A) serotonin receptors .

Dosage

Myoril Plus dosage

Ketoprofen Tablet: Oral treatment with Ketoprofen is 50-100 mg daily, taken with food to minimize gastrointestinal disturbance. For rheumatic disease, 100-200 mg daily in 2-4 divided doses with food. For pain and dysmenorrhoea, 50 mg up to 3 times daily.

Ketoprofen SR Capsule: 100-200 mg once daily, depending on patient’s weight and on severity of symptomsKetoprofen IM injection:

• Adults: 50 to 100 mg every four hours, repeated up to a maximum of 200 mg in twenty-four hours for up to 3 days. Following a satisfactory response oral therapy should be instituted with Ketoprofen tablet. It is recommended that the injection should not normally be continued for longer than three days.
• Elderly: As with other medications it is generally advisable in the elderly to begin ketoprofen therapy at the lower end of the dose range and to maintain such patients on the lowest effective dosage.
• Paediatric dosage: Not established for intramuscular use. It is not used as intravenous injection.

Ketoprofen 2.5% Gel: Thisis to be applied to the painful area twice daily.The gel can be used with an occlusive dressing. Rub gently into the skin to ensure penetration.

For children: There is no contraindication to the use of this drug in children, but the appropriate dosage has not yet been established. Dosage of Ketoprofen must be carefully adjusted according to individual requirements and response, using the lower possible effective dosage. Dosage exceeding 300 mg daily has not been adequately studied and are not recommended.

Suppository: 1 suppository (100 mg) late at night supplemented as required with Ketoprofen capsules during daytime. Ketoprofen suppositories are especially appropriate for controlling overnight symptoms (severity of night and morning pain; duration and severity of morning stiffness). Suppositoriesadministered late at night provide more consistent effective control of overnight symptoms than oral medication.

Side Effects

Adverse reactions to Ketoprofen are usually mild and mainly involve the GI tract, particularly upper GI tract. Most Ketoprofen-induced adverse effects occur during the first month of treatment, and the frequency of adverse effects generally decreases with continued therapy.

Adverse reactions involving digestive system are dyspepsia, nausea, abdominal pain, diarrhoea, constipation, flatulence, anorexia, vomiting, stomatitis and that involving nervous system are headache, dizziness, malaise, depression, nervousness, dreams, etc. Other reactions are tinnitus, visual disturbance, rash, impairment of renal function, signs or symptoms of urinary-tract irritation.

Toxicity

LD₅₀=62.4 mg/kg (rat, oral).

Symptoms of overdose include drowsiness, vomiting and abdominal pain.

Side effects are usually mild and mainly involved the GI tract. Most common adverse GI effect is dyspepsia (11% of patients). May cause nausea, diarrhea, abdominal pain, constipation and flatulence in greater than 3% of patients.

Has been shown to cause chromosomal aneuploidy and male infertility. Should be avoided during all stages of pregnancy, lactation and puberty. Is a potential risk factor for cancer.

In 2013, The European Medical Association (EMA) mandated that the use of thiocolchicoside-containing medicines by mouth or injection should be restricted across the European Union (EU). These drugs are now recommended only as an add-on treatment for painful muscle contractures resulting from spinal conditions in adults and adolescents 16 years old and older. Additionally, the dose of thiocolchicoside by mouth or injection should be limited. This is due to experimental evidence suggesting that thiocolchicoside was metabolized into M2 or SL59.0955, that has the propensity to damage dividing cells, resulting in aneuploidy (an abnormal number or arrangement of chromosomes). As a result, the CHMP (committee for medicinal products for human use) examined the safety profile of this medicine and consider what regulatory action might be appropriate .

The CHMP reviewed the evidence, with consideration of opinions from experts in medicines safety, and concluded that aneuploidy may occur with M2 at levels not significantly greater than those measured after recommended doses of thiocolchicoside ingested orally. Aneuploidy is a strong risk factor for fetal harm, decreased fertility in men, and could theoretically increase the risk of developing cancer .

The maximum recommended oral dose is 8 mg every 12 hours; treatment length should not exceed 7 consecutive days. When given intramuscularly (IM), the maximum dose is 4 mg every 12 hours, for a maximum of 5 days .

In addition to the above toxicity, a study was done on the hepatotoxic potential of thiocolchicoside. It was observed that serum AST and ALT levels increased following of the administration oral thiocolchicoside at 8 mg/day. Two weeks after discontinuing thiocolchicoside therapy, liver enzymes had decreased to levels within the normal range. Although infrequent, thiocolchicoside should be considered a rare hepatotoxic agent in clinical practice .

Precaution

Ketoprofen should be used with caution in patients who may be adversely affected by a prolongation of bleeding time (e.g. patients receiving anticoagulant therapy), since the drug may inhibit platelet function.

Ketoprofen should be used with caution in patients with heart failure, hypertension, or other conditions associated with fluid retention, since peripheral edema has been observed in some patients receiving the drug.

Liver function should be monitored periodically during long-term Ketoprofen therapy.

Ketoprofen injection must not be given intravenously.

Ketoprofen gel should not be applied to patients who have allergy toketoprofen, other anti-inflammatory agents and aspirin.

Interaction

As Ketoprofen may cause GI bleeding, inhibit platelet aggregation and prolong bleeding time, the drug should be used with caution and the patient should be carefully observed if the drug is used concomitantly with any anticoagulant or thrombolytic agent. Concomitant administration of Ketoprofen and hydrochlorothiazide has resulted in decreased urinary excretion of potassium and chloride compared with hydrochlorothiazide alone. Ketoprofen and salicylates appear to interact in a complex manner and they should not be used concomitantly. Concomitant use of Ketoprofen and probenecid is also not recommended. Ketoprofen should be avoided in patients receiving methotrexate.

Volume of Distribution

The apparent volume of distribution of thiocolchicoside is estimated to be approximately 42.7 L after an intramuscular injection of 8 mg .

Elimination Route

Ketoprofen is rapidly and well-absorbed orally, with peak plasma levels occurring within 0.5 to 2 hours.

Oral bioavailability is ~25% After intramuscular administration, thiocolchicoside Cmax occur in 30 min and .reach values of 113 ng/mL after a 4 mg dose and 175 ng/mL after a 8 mg dose. The corresponding values of AUC are respectively 283 and 417 ng.h/mL. The pharmacologically active metabolite SL18.0740 is found at lower concentrations with a Cmax of 11.7 ng/mL occurring 5 h post administration and an AUC of 83 ng.h/mL .

After oral administration, no thiocolchicoside is detected in plasma. Only two metabolites are observed: The pharmacologically active metabolite SL18.0740 and an inactive metabolite SL59.0955. For both metabolites, maximum plasma concentrations occur 1hour after thiocolchicoside administration. After a single oral dose of 8 mg of thiocolchicoside the Cmax and AUC of SL18.0740 are about 60 ng/mL and 130 ng.h/mL respectively. For SL59.0955 these values are much lower: Cmax around 13 ng/mL and AUC ranging from 15.5 ng.h/mL (until 3h) to 39.7 ng.h/mL (until 24h) .

Half Life

Conventional capsules: 1.1-4 hours

Extended release capsules: 5.4 hours due to delayed absorption (intrinsic clearance is same as conventional capsules)

Approximately 7.7h .

Clearance

• Oral-dose cl=6.9 +/- 0.8 L/h [Ketoprofen Immediate-release capsules (4 × 50 mg)]
• Oral-dose cl=6.8 +/- 1.8 L/h [Ketoprofen Extended-release capsules (1 × 200 mg)]
• 0.08 L/kg/h
• 0.7 L/kg/h [alcoholic cirrhosis patients]

Primarily extrarenal elimination (75% of the total body clearance) .

Elimination Route

In a 24 hour period, approximately 80% of an administered dose of ketoprofen is excreted in the urine, primarily as the glucuronide metabolite.

Thiocolchicoside is not eliminated unchanged, rather as one of three metabolites found in either feces (~79 %) or in urine 20%. 3- demethylcolchicine (M2) and 3-O-glucurono-demethylcolchicine (M1) are found in both urine and feces, where as di-demethylcolchicine is found only in feces .

Pregnancy & Breastfeeding use

Embryopathic effects have not been recorded with Ketoprofen, but it is recommended to avoid medication during pregnancy. Trace amounts of the drug appear in breast milk and it should not be used during breast feeding unless unavoidable.

Contraindication

Ketoprofen is contraindicated in patients with known hypersensitivity to the drug. Ketoprofen is contraindicated in patients in whom asthma, urticaria, or other sensitivity reaction is precipitated by aspirins or other NSAIDs, since severe, rarely fatal, anaphylactic reactions to Ketoprofen have been reported in these patients.

The risk of potentially serious adverse GI effects should be considered in patients receiving Ketoprofen, particularly in patients receiving chronic therapy with the drug. Ketoprofen should be used in patients with GI bleeding or active peptic ulceration only when the potential benefits justify the possible risks.

Storage Condition

Store at cool and dry place, protect from light and moisture. Keep out of the children’s reach.

Innovators Monograph

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