India Product

Prokrab Capsule

Prokrab Capsule

Why you have been prescribed this medicine?

You have been prescribed this medicine if you have any of the following:

●Healing of Erosive or Ulcerative Gastroesophageal Reflux Disease (GERD).
●Maintenance of Healing of Erosive or Ulcerative Gastroesophageal Reflux Disease (GERD)
●Healing of Duodenal Ulcers.
●Treatment of Pathological Hypersecretory Conditions, Including Zollinger Ellison Syndrome.
●Irritable bowel syndrome.
●Chronic Gastritis.



What to do if you miss a dose?

If it is almost time for your next dose, skip the dose you missed and take your next dose when you are meant to. Otherwise take it as soon as you remember and then go back to taking it as you would normally.


You should consult your doctor if you experience any of the following:

Rabeprazole:

The most commonly reported adverse drug reactions, during controlled clinical trials with rabeprazole were headache, diarrhoea, abdominal pain, asthenia, flatulence, rash and dry mouth. The majority of adverse events experienced during clinical studies were mild or moderate in severity, and transient in nature.
The following adverse events have been reported from clinical trial and post-marketing experience.
Frequencies are defined as: common (> 1/100, < 1/10), uncommon (> 1/1,000, < 1/100), rare (>1/10,000, <1/1000) very rare (<1/10,000), not known (cannot be estimated from the available data).

System Organ Class

Common

Uncommon

Rare

Very Rare

Not Known

Infections and infestations

Infection

 

 

 

 

Blood and the lymphatic system disorders

 

 

Neutropenia
Leucopenia
Thrombocytopenia
Leucocytosis

 

 

Immune system disorders

 

 

Hypersensitivity1,2

 

 

Metabolism and nutrition disorders

 

 

Anorexia

 

Hyponatremia
Hypomagnesaemia4

Psychiatric disorders

Insomnia

Nervousness

Depression

 

Confusion

Nervous system disorders

Headache
Dizziness

Somnolence

 

 

 

Eye disorders

 

 

Visual disturbance

 

 

Vascular Disorders

 

 

 

 

Peripheral Oedema

Respiratory, thoracic and mediastinal disorders

Cough
Pharyngitis
Rhinitis

Bronchitis
Sinusitis

 

 

 

Gastrointestinal disorders

Diarrhoea
Vomiting
Nausea
Abdominal pain
Constipation
Flatulence

Dyspepsia
Dry mouth
Eructation

Gastritis
Stomatitis
Taste disturbance

 

 

Hepato-biliary disorders

 

 

Hepatitis
Jaundice
Hepatic encephalopathy3

 

 

Skin and subcutaneous tissue disorders

 

Rash
Erythema2

Pruritus
Sweating
Bullous reactions2

Erythema multiforme, toxic epidermal necrolysis (TEN), Stevens-Johnson syndrome (SJS)

Subacute cutaneous lupus erythematosus4

Musculoskeletal connective tissue and bone disorders

Non-specific pain
Back pain

Myalgia
Leg cramps
Arthralgia
Fracture of the hip, wrist or spine 4

 

 

 

Renal and urinary disorders

 

Urinary tract infection

Interstitial nephritis

 

 

Reproductive system and breast disorders

 

 

 

 

Gynaecomastia

General disorders and administration site conditions

Asthenia
Influenza like illness

Chest pain
Chills
Pyrexia

 

 

 

Investigations

 

Increased hepatic enzymes3

Weight increased

 

 

1 Includes facial swelling, hypotension and dyspnoea
2 Erythema, bullous reactions and hypersensitivity reactions have usually resolved after discontinuation of therapy.
3 Rare reports of hepatic encephalopathy have been received in patients with underlying cirrhosis. In treatment of patients with severe hepatic dysfunction the prescriber is advised to exercise caution when treatment with PROKRAB is first initiated in such patients.
4 See Special warnings and precautions for use.

Levosulpiride:

Blurred vision, mydriasis, tachycardia, ECG changes, orthostatic hypotension, priapism, impotence, hypersensitivity reactions, jaundice, blood disorders, extrapyramidal dysfunction, congestion, inhibition of ejaculation, Sleep disturbances, overstimulation, agitation, dry mouth, constipation, difficulty with micturition, weight gain, hyperglycemia & altered glucose tolerance, delirium, insomnia, drowsiness, depression.

 

Things you MUST NOT DO while on this medicine?

RABEPRAZOLE:
Symptomatic response to therapy with rabeprazole sodium does not preclude the presence of gastric or oesophageal malignancy, therefore the possibility of malignancy should be excluded prior to commencing treatment with PROKRAB.
Patients on long-term treatment (particularly those treated for more than a year) should be kept under regular surveillance.
A risk of cross-hypersensitivity reactions with other proton pump inhibitor or substituted benzimidazoles cannot be excluded.
Patients should be cautioned that PROKRAB capsules should not be chewed or crushed, but should be swallowed whole.
PROKRAB is not recommended for use in children, as there is no experience of its use in this group.
There have been post marketing reports of blood dyscrasias (thrombocytopenia and neutropenia). In the majority of cases where an alternative aetiology cannot be identified, the events were uncomplicated and resolved on discontinuation of rabeprazole.
Hepatic enzyme abnormalities have been seen in clinical trials and have also been reported since market authorisation. In the majority of cases where an alternative aetiology cannot be identified, the events were uncomplicated and resolved on discontinuation of rabeprazole.
No evidence of significant drug related safety problems was seen in a study of patients with mild to moderate hepatic impairment versus normal age and sex matched controls. However because there are no clinical data on the use of PROKRABin the treatment of patients with severe hepatic dysfunction the prescriber is advised to exercise caution when treatment with PROKRAB is first initiated in such patients.
Co-administration of atazanavir with PROKRAB is not recommended .
Treatment with proton pump inhibitors, including PROKRAB, may possibly increase the risk of gastrointestinal infections such as Salmonella, Campylobacter and Clostridium difficile.
Proton pump inhibitors, especially if used in high doses and over long durations (>1 year), may modestly increase the risk of hip, wrist and spine fracture, predominantly in older people or in presence of other recognised risk factors. Observational studies suggest that proton pump inhibitors may increase the overall risk of fracture by 10–40%. Some of this increase may be due to other risk factors. Patients at risk of osteoporosis should receive care according to current clinical guidelines and they should have an adequate intake of vitamin D and calcium.
Severe hypomagnesaemia has been reported in patients treated with proton pump inhibitors like PROKRABfor at least three months, and in most cases for a year. Serious manifestations of hypomagnesaemia such as fatigue, tetany, delirium, convulsions, dizziness and ventricular arrhythmia can occur but they may begin insidiously and be overlooked. In most affected patients, hypomagnesaemia improved after magnesium replacement and discontinuation of the proton pump inhibitor.
For patients expected to be on prolonged treatment or who take proton pump inhibitors with digoxin or drugs that may cause hypomagnesaemia (e.g., diuretics), health care professionals should consider measuring magnesium levels before starting proton pump inhibitor treatment and periodically during treatment.

Concomitant use of Rabeprazole with Methotrexate
Literature suggests that concomitant use of PPIs with methotrexate (primarily at high dose; see methotrexate prescribing information) may elevate and prolong serum levels of methotrexate and/or its metabolite, possibly leading to methotrexate toxicities. In high-dose methotrexate administration, a temporary withdrawal of the PPI may be considered in some patients.

Influence on vitamin B12 absorption
Rabeprazole sodium, as all acid-blocking medicines, may reduce the absorption of vitamin B12 (cyanocobalamin) due to hypo- or a- chlorhydria. This should be considered in patients with reduced body stores or risk factors for reduced vitamin B12 absorption on long-term therapy or if respective clinical symptoms are observed.

Subacute cutaneous lupus erythematosus (SCLE)
Proton pump inhibitors are associated with very infrequent cases of SCLE. If lesions occur, especially in sun-exposed areas of the skin, and if accompanied by arthralgia, the patient should seek medical help promptly and the health care professional should consider stopping PROKRAB. SCLE after previous treatment with a proton pump inhibitor may increase the risk of SCLE with other proton pump inhibitors.

 

LEVOSULPIRIDE:

Manic/hypomanic patients, impaired hepatic/renal, cerebrovascular, respiratory function, those with angleclosure glaucoma, history of jaundice, Parkinsonism, DM, hypothyroidism, myasthenia gravis, paralytic ileus, prostatic hyperplasia, urinary retention (if possible avoid), epilepsy/history of seizures, debilitated patients, elderly, should not drive/operate machinery, presence of acute infect/leucopenia, avoid abrupt withdrawal.

 

Ability to influence reaction velocity while driving or operating any other mechanisms.
Based on the pharmacodynamic properties and the adverse events profile, it is unlikely that Prokrab would cause an impairment of driving performance or compromise the ability to use machinery. If however, alertness is impaired due to somnolence, it is recommended that driving and operating complex machinery be avoided.

 

What to do if you accidentally take too much (overdose) of the medicine?

Experience to date with deliberate or accidental overdose is limited. The maximum established exposure has not exceeded 60mg twice daily, or 160mg once daily. Effects are generally minimal, representative of the known adverse event profile and reversible without further medical intervention. No specific antidote is known. Rabeprazole sodium is extensively protein bound and is, therefore, not dialyzable. As in any case of overdose, treatment should be symptomatic and general supportive measures should be utilized.

Is it safe in pregnancy and breast-feeding?

Pregnancy:
There are no data on the safety of rabeprazole in human pregnancy.
Reproduction studies performed in rats and rabbits have revealed no evidence of impaired fertility or harm to the foetus due to rabeprazole sodium, although low foeto-placental transfer occurs in rats. PROKRAB is contraindicated during pregnancy.

Breast-feeding:
It is not known whether rabeprazole sodium is excreted in human breast milk. No studies in breast-feeding women have been performed. Rabeprazole sodium is however excreted in rat mammary secretions. Therefore PROKRAB should not be used during breast-feeding.

 

Storage Conditions:

Store at the temperature not more than 30°С in dry place.
Keep out of reach of children.

Drug Description

Active substance: Rabeprazole sodium; Levosulpiride.
1 capsule contains 20 mg of Rabeprazole sodium; Levosulpiride 75 mg.

Excipients: Non pareil seeds.

Indications and dosage.

Active substance: Rabeprazole sodium; Levosulpiride.
1 capsule contains 20 mg of Rabeprazole sodium; Levosulpiride 75 mg.

Excipients: Non pareil seeds.

 

Side effects and drug interactions.

Adverse reactions:
Rabeprazole:
The most commonly reported adverse drug reactions, during controlled clinical trials with rabeprazole were headache, diarrhoea, abdominal pain, asthenia, flatulence, rash and dry mouth. The majority of adverse events experienced during clinical studies were mild or moderate in severity, and transient in nature.
The following adverse events have been reported from clinical trial and post-marketing experience.
Frequencies are defined as: common (> 1/100, < 1/10), uncommon (> 1/1,000, < 1/100), rare (>1/10,000, <1/1000) very rare (<1/10,000), not known (cannot be estimated from the available data).

System Organ Class

Common

Uncommon

Rare

Very Rare

Not Known

Infections and infestations

Infection

 

 

 

 

Blood and the lymphatic system disorders

 

 

Neutropenia
Leucopenia
Thrombocytopenia
Leucocytosis

 

 

Immune system disorders

 

 

Hypersensitivity1,2

 

 

Metabolism and nutrition disorders

 

 

Anorexia

 

Hyponatremia
Hypomagnesaemia4

Psychiatric disorders

Insomnia

Nervousness

Depression

 

Confusion

Nervous system disorders

Headache
Dizziness

Somnolence

 

 

 

Eye disorders

 

 

Visual disturbance

 

 

Vascular Disorders

 

 

 

 

Peripheral Oedema

Respiratory, thoracic and mediastinal disorders

Cough
Pharyngitis
Rhinitis

Bronchitis
Sinusitis

 

 

 

Gastrointestinal disorders

Diarrhoea
Vomiting
Nausea
Abdominal pain
Constipation
Flatulence

Dyspepsia
Dry mouth
Eructation

Gastritis
Stomatitis
Taste disturbance

 

 

Hepato-biliary disorders

 

 

Hepatitis
Jaundice
Hepatic encephalopathy3

 

 

Skin and subcutaneous tissue disorders

 

Rash
Erythema2

Pruritus
Sweating
Bullous reactions2

Erythema multiforme, toxic epidermal necrolysis (TEN), Stevens-Johnson syndrome (SJS)

Subacute cutaneous lupus erythematosus4

Musculoskeletal connective tissue and bone disorders

Non-specific pain
Back pain

Myalgia
Leg cramps
Arthralgia
Fracture of the hip, wrist or spine 4

 

 

 

Renal and urinary disorders

 

Urinary tract infection

Interstitial nephritis

 

 

Reproductive system and breast disorders

 

 

 

 

Gynaecomastia

General disorders and administration site conditions

Asthenia
Influenza like illness

Chest pain
Chills
Pyrexia

 

 

 

Investigations

 

Increased hepatic enzymes3

Weight increased

 

 

1 Includes facial swelling, hypotension and dyspnoea
2 Erythema, bullous reactions and hypersensitivity reactions have usually resolved after discontinuation of therapy.
3 Rare reports of hepatic encephalopathy have been received in patients with underlying cirrhosis. In treatment of patients with severe hepatic dysfunction the prescriber is advised to exercise caution when treatment with PROKRAB is first initiated in such patients.
4 See Special warnings and precautions for use.

Levosulpiride:

Blurred vision, mydriasis, tachycardia, ECG changes, orthostatic hypotension, priapism, impotence, hypersensitivity reactions, jaundice, blood disorders, extrapyramidal dysfunction, congestion, inhibition of ejaculation, Sleep disturbances, overstimulation, agitation, dry mouth, constipation, difficulty with micturition, weight gain, hyperglycemia & altered glucose tolerance, delirium, insomnia, drowsiness, depression.

 

           Drug interactions
Rabeprazole sodium produces a profound and long lasting inhibition of gastric acid secretion. An interaction with compounds whose absorption is pH dependent may occur. Co-administration of rabeprazole sodium with ketoconazole or itraconazole may result in a significant decrease in antifungal plasma levels. Therefore individual patients may need to be monitored to determine if a dosage adjustment is necessary when ketoconazole or itraconazole are taken concomitantly with PROKRAB.
Moclobemide may enhance the adverse effects of levosulpiride.
Magnesium Hydroxide/Aluminium hydroxide/Sucralfate reduces drug absorption.
In clinical trials, antacids were used concomitantly with the administration of PROKRABand, in a specific drug-drug interaction study, no interaction with liquid antacids was observed.
Co-administration of atazanavir 300 mg/ritonavir 100 mg with omeprazole (40 mg once daily) or atazanavir 400 mg with lansoprazole (60 mg once daily) to healthy volunteers resulted in a substantial reduction in atazanavir exposure. The absorption of atazanavir is pH dependent. Although not studied, similar results are expected with other proton pump inhibitors. Therefore PPIs, including rabeprazole, should not be co-administered with atazanavir.

Methotrexate
Case reports, published population pharmacokinetic studies, and retrospective analyses suggest that concomitant administration of PPIs and methotrexate (primarily at high dose; see methotrexate prescribing information) may elevate and prolong serum levels of methotrexate and/or its metabolite hydroxymethotrexate. However, no formal drug interaction studies of methotrexate with PPIs have been conducted.

Concomitant use of the following substances is contraindicated
QTc-prolonging medicinal products
• anti-arrhythmics class IA (e.g., disopyramide, hydroquinidine, quinidine)
• anti-arrhythmics class III (e.g., amiodarone, dofetilide, dronedarone, ibutilide, sotalol)
• certain antipsychotics (e.g., haloperidol, pimozide, sertindole)
• certain antidepressants (e.g., citalopram, escitalopram)
• certain antibiotics (e.g., erythromycin, levofloxacin, moxifloxacin, spiramycin)
• certain antifungal agents (e.g., pentamidine)
• certain antimalarial agents (in particular halofantrine, lumefantrine)
• certain gastro-intestinal medicines (e.g., cisapride, dolasetron,   prucalopride)
• certain antihistaminics (e.g., mequitazine, mizolastine)
• certain medicines used in cancer (e.g., toremifene, vandetanib, vincamine)
• certain other medicines (e.g., bepridil, diphemanil, methadone).
• Potent CYP3A4 inhibitors (regardless of their QT prolonging effects), i.e :
protease inhibitors
• systemic azole antifungals
• some macrolides (erythromycin, clarithromycin and telithromycin).

 

Warnings and precautions

RABEPRAZOLE:
Symptomatic response to therapy with rabeprazole sodium does not  preclude the presence of gastric or oesophageal malignancy, therefore the possibility of malignancy should be excluded prior to commencing treatment with PROKRAB.
Patients on long-term treatment (particularly those treated for more than a year) should be kept under regular surveillance.
A risk of cross-hypersensitivity reactions with other proton pump inhibitor or substituted benzimidazoles cannot be excluded.
Patients should be cautioned that PROKRAB capsules should not be chewed or crushed, but should be swallowed whole.
PROKRAB is not recommended for use in children, as there is no experience of its use in this group.
There have been post marketing reports of blood dyscrasias (thrombocytopenia and neutropenia). In the majority of cases where an alternative aetiology cannot be identified, the events were uncomplicated and resolved on discontinuation of rabeprazole.
Hepatic enzyme abnormalities have been seen in clinical trials and have also been reported since market authorisation. In the majority of cases where an alternative aetiology cannot be identified, the events were uncomplicated and resolved on discontinuation of rabeprazole.
No evidence of significant drug related safety problems was seen in a study of patients with mild to moderate hepatic impairment versus normal age and sex matched controls. However because there are no clinical data on the use of PROKRABin the treatment of patients with severe hepatic dysfunction the prescriber is advised to exercise caution when treatment with PROKRAB is first initiated in such patients.
Co-administration of atazanavir with PROKRAB is not recommended .
Treatment with proton pump inhibitors, including PROKRAB, may possibly increase the risk of gastrointestinal infections such as Salmonella, Campylobacter and Clostridium difficile.
Proton pump inhibitors, especially if used in high doses and over long durations (>1 year), may modestly increase the risk of hip, wrist and spine fracture, predominantly in older people or in presence of other recognised risk factors. Observational studies suggest that proton pump inhibitors may increase the overall risk of fracture by 10–40%. Some of this increase may be due to other risk factors. Patients at risk of osteoporosis should receive care according to current clinical guidelines and they should have an adequate intake of vitamin D and calcium.
Severe hypomagnesaemia has been reported in patients treated with proton pump inhibitors like PROKRABfor at least three months, and in most cases for a year. Serious manifestations of hypomagnesaemia such as fatigue, tetany, delirium, convulsions, dizziness and ventricular arrhythmia can occur but they may begin insidiously and be overlooked. In most affected patients, hypomagnesaemia improved after magnesium replacement and discontinuation of the proton pump inhibitor.
For patients expected to be on prolonged treatment or who take proton pump inhibitors with digoxin or drugs that may cause hypomagnesaemia (e.g., diuretics), health care professionals should consider measuring magnesium levels before starting proton pump inhibitor treatment and periodically during treatment.

          Concomitant use of Rabeprazole with Methotrexate
Literature suggests that concomitant use of PPIs with methotrexate (primarily at high dose; see methotrexate prescribing information) may elevate and prolong serum levels of methotrexate and/or its metabolite, possibly leading to methotrexate toxicities. In high-dose methotrexate administration, a temporary withdrawal of the PPI may be considered in some patients.
Influence on vitamin B12 absorption
Rabeprazole sodium, as all acid-blocking medicines, may reduce the absorption of vitamin B12 (cyanocobalamin) due to hypo- or a- chlorhydria. This should be considered in patients with reduced body stores or risk factors for reduced vitamin B12 absorption on long-term therapy or if respective clinical symptoms are observed.
           Subacute cutaneous lupus erythematosus (SCLE)
Proton pump inhibitors are associated with very infrequent cases of SCLE. If lesions occur, especially in sun-exposed areas of the skin, and if accompanied by arthralgia, the patient should seek medical help promptly and the health care professional should consider stopping PROKRAB. SCLE after previous treatment with a proton pump inhibitor may increase the risk of SCLE with other proton pump inhibitors.

          LEVOSULPIRIDE:
Manic/hypomanic patients, impaired hepatic/renal, cerebrovascular, respiratory function, those with angleclosure glaucoma, history of jaundice, Parkinsonism, DM, hypothyroidism, myasthenia gravis, paralytic ileus, prostatic hyperplasia, urinary retention (if possible avoid), epilepsy/history of seizures, debilitated patients, elderly, should not drive/operate machinery, presence of acute infect/leucopenia, avoid abrupt withdrawal.

Overdosage and Contraindications

Overdosage:
Experience to date with deliberate or accidental overdose is limited. The maximum established exposure has not exceeded 60mg twice daily, or 160mg once daily. Effects are generally minimal, representative of the known adverse event profile and reversible without further medical intervention. No specific antidote is known. Rabeprazole sodium is extensively protein bound and is, therefore, not dialyzable. As in any case of overdose, treatment should be symptomatic and general supportive measures should be utilized.

              Contraindications

  • PROKRAB is contra-indicated in patients with known hypersensitivity to rabeprazole sodium, levosulpiride or to any excipient used in the formulation.
  • Preexisting CNS depression/coma.
  • Prolactin-releasing pituitary tumour (prolactinoma.), pheochromocytoma.
  • In patients with moderate or severe hepatic impairment.

In patients with bone marrow suppression. In patients who have known existing prolongation of cardiac conduction intervals, particularly QTc, patients with significant electrolyte disturbances or underlying cardiac disease such as congestive heart failure.

  • Patients with undue exposure to direct sunlight.
  • Co-administration with QT-prolonging drugs.
  • Co-administration with potent CYP3A4 inhibitors (regardless of their QT prolonging effects).

Clinical pharmacology.

Pharmacodynamic properties

Pharmacotherapeutic group: Alimentary tract and metabolism, Drugs for peptic ulcer and gastro-oesophageal reflux disease (GORD), proton pump inhibitors, ATC code: A02B C04

Mechanism of Action:

Rabeprazole:

Rabeprazole sodium belongs to the class of anti-secretory compounds, the substituted benzimidazoles, that do not exhibit anticholinergic or H2 histamine antagonist properties, but suppress gastric acid secretion by the specific inhibition of the H+/K+-ATPase enzyme (the acid or proton pump) The effect is dose-related and leads to inhibition of both basal and stimulated acid secretion irrespective of the stimulus. Animal studies indicate that after administration, rabeprazole sodium rapidly disappears from both the plasma and gastric mucosa. As a weak base, rabeprazole is rapidly absorbed following all doses and is concentrated in the acid environment of the PROKRABal cells. Rabeprazole is converted to the active sulphenamide form through protonation and it subsequently reacts with the available cysteines on the proton pump.
Anti-secretory Activity: After oral administration of a 20mg dose of rabeprazole sodium the onset of the anti-secretory effect occurs within one hour, with the maximum effect occurring within two to four hours. Inhibition of basal and food stimulated acid secretion 23 hours after the first dose of rabeprazole sodium are 69% and 82% respectively and the duration of inhibition lasts up to 48 hours. The inhibitory effect of rabeprazole sodium on acid secretion increases slightly with repeated once-daily dosing, achieving steady state inhibition after three days. When the drug is discontinued, secretory activity normalises over 2 to 3 days.
Decreased gastric acidity due to any means, including proton pump inhibitors such as rabeprazole, increases counts of bacteria normally present in the gastrointestinal tract. Treatment with proton pump inhibitors may possibly increase the risk of gastrointestinal infections such as Salmonella, Campylobacter and Clostridium difficile.
Serum Gastrin Effects: In clinical studies patients were treated once daily with 10 or 20mg rabeprazole sodium, for up to 43 months duration. Serum gastrin levels increased during the first 2 to 8 weeks reflecting the inhibitory effects on acid secretion and remained stable while treatment was continued. Gastrin values returned to pre-treatment levels, usually within 1 to 2 weeks after discontinuation of therapy.
Human gastric biopsy specimens from the antrum and the fundus from over 500 patients receiving rabeprazole or comparator treatment for up to 8 weeks have not detected changes in ECL cell histology, degree of gastritis, incidence of atrophic gastritis, intestinal metaplasia or distribution of H. pylori infection. In over 250 patients followed for 36 months of continuous therapy, no significant change in findings present at baseline was observed.
Other Effects: Systemic effects of rabeprazole sodium in the CNS, cardiovascular and respiratory systems have not been found to date. Rabeprazole sodium, given in oral doses of 20mg for 2 weeks, had no effect on thyroid function, carbohydrate metabolism, or circulating levels of parathyroid hormone, cortisol, oestrogen, testosterone, prolactin, cholecystokinin, secretin, glucagon, follicle stimulating hormone (FSH), luteinising hormone (LH), renin, aldosterone or somatotrophic hormone.
Studies in healthy subjects have shown that rabeprazole sodium does not have clinically significant interactions with amoxicillin. Rabeprazole does not adversely influence plasma concentrations of amoxicillin or clarithromycin when co-administered for the purpose of eradicating upper gastrointestinal H. pylori infection.

Levosulpiride:
The prokinetic effect of Levosulpiride is mediated through the blockade of enteric (neuronal and muscular) inhibitory dopamine D2 receptors. Results also show that levosulpiride also acts as a  moderate agonist at the 5HT receptor. The serotonergic (5HT4) component of Levosulpiride may enhance its therapeutic efficacy in gastrointestinal disorders. This property, together with antagonism at D2 receptors, may contribute to its gastrointestinal prokinetic effect.
          Pharmacokinetic properties

          Rabeprazole:

Absorption: Prokrab is an enteric-coated (gastro-resistant) capsule formulation of rabeprazole sodium. This presentation is necessary because rabeprazole is acid-labile.
Absorption of rabeprazole therefore begins only after the capsule leaves the stomach. Absorption is rapid, with peak plasma levels of rabeprazole occurring approximately 3.5 hours after a 20mg dose. Peak plasma concentrations (Cmax) of rabeprazole and AUC are linear over the dose range of 10mg to 40mg. Absolute bioavailability of an oral 20mg dose (compared to intravenous administration) is about 52% due in large part to pre-systemic metabolism. Additionally the bioavailability does not appear to increase with repeat administration. In healthy subjects the plasma half-life is approximately one hour (range 0.7 to 1.5 hours), and the total body clearance is estimated to be 283 ± 98 ml/min. There was no clinically relevant interaction with food. Neither food nor the time of day of administration of the treatment affect the absorption of rabeprazole sodium.

Distribution: Rabeprazole is approximately 97% bound to human plasma proteins.

Metabolism and excretion: Rabeprazole sodium, as is the case with other members of the proton pump inhibitor (PPI) class of compounds, is metabolised through the cytochrome P450 (CYP450) hepatic drug metabolising system. In vitro studies with human liver microsomes indicated that rabeprazole sodium is metabolised by isoenzymes of CYP450 (CYP2C19 and CYP3A4). In these studies, at expected human plasma concentrations rabeprazole neither induces nor inhibits CYP3A4; and although in vitro studies may not always be predictive of in vivo status these findings indicate that no interaction is expected between rabeprazole and cyclosporin. In humans the thioether (M1) and carboxylic acid (M6) are the main plasma metabolites with the sulphone (M2), desmethyl-thioether (M4) and mercapturic acid conjugate (M5) minor metabolites observed at lower levels. Only the desmethyl metabolite (M3) has a small amount of anti-secretory activity, but it is not present in plasma.
Following a single 20mg 14C labelled oral dose of rabeprazole sodium, no unchanged drug was excreted in the urine. Approximately 90% of the dose was eliminated in urine mainly as the two metabolites: a mercapturic acid conjugate (M5) and a carboxylic acid (M6), plus two unknown metabolites. The remainder of the dose was recovered in faeces.

Gender: Adjusted for body mass and height, there are no significant gender differences in pharmacokinetic parameters following a single 20 mg dose of rabeprazole.

Renal dysfunction: In patients with stable, end-stage, renal failure requiring maintenance haemodialysis (creatinine clearance ≤5ml/min/1.73 m2), the disposition of rabeprazole was very similar to that in healthy volunteers. The AUC and the Cmax in these patients was about 35% lower than the corresponding parameters in healthy volunteers. The mean half-life of rabeprazole was 0.82 hours in healthy volunteers, 0.95 hours in patients during haemodialysis and 3.6 hours post dialysis. The clearance of the drug in patients with renal disease requiring maintenance haemodialysis was approximately twice that in healthy volunteers.

Hepatic dysfunction: Following a single 20 mg dose of rabeprazole to patients with chronic mild to moderate hepatic impairment the AUC doubled and there was a 2-3 fold increase in half-life of rabeprazole compared to the healthy volunteers. However, following a 20 mg dose daily for 7 days the AUC had increased to only 1.5-fold and the Cmax to only 1.2-fold. The half-life of rabeprazole in patients with hepatic impairment was 12.3 hours compared to 2.1 hours in healthy volunteers. The pharmacodynamic response (gastric pH control) in the two groups was clinically comparable.

Older people: Elimination of rabeprazole was somewhat decreased in older people. Following 7 days of daily dosing with 20mg of rabeprazole sodium, the AUC approximately doubled, the Cmax increased by 60% and t½ increased by approximately 30% as compared to young healthy volunteers. However there was no evidence of rabeprazole accumulation.
CYP2C19 Polymorphism: Following a 20mg daily dose of rabeprazole for 7 days, CYP2C19 slow metabolisers, had AUC and t½ which were approximately 1.9 and 1.6 times the corresponding parameters in extensive metabolisers whilst Cmax had increased by only 40%.

Levosulpiride:

Absorption: Oral bioavailability is about 30%; peak plasma concentrations after about 3hr.
Route of Elimination: Mainly via urine. Plasma halflife: 9.7 hr (oral); 4.3 hr (IV).

Pharmaceutical characteristics:

General physic-chemical properties:  Purple/Orange coloured hard gelatin capsule size “0” filled with white & reddish chocolate coloured pellets and one off white uncoated coloured tablet.

Shelf-life: 2 years.

Storage: Store at the temperature not more than 30°С in dry place.
Keep out of reach of children.

Package: 10 capsules in alu-alu blisters.

Conditions of supply: By prescription.

 

CERTIFICATES

KEEP IN TOUCH

Kusum Healthcare Pvt Ltd

Regd. Office: D-158A, Okhla Industrial Area

Phase-1, New Delhi-110020, India

Tel: 011-41005147, 40514919

Fax: +91-11-40527575

Email: kusumhealth@kusumhealthcare.com

CIN: U65929DL1997PTC085780