Flurazepam 15 Product Monograph

ACTIONS AND CLINICAL PHARMACOLOGY

Flurazepam (flurazepam hydrochloride), a benzodiazepine derivative, is a hypnotic agent which does not appear to decrease dream time as measured by rapid eye movements (REM). Flurazepam decreases sleep latency and number of awakenings for a consequent increase in total sleep time.

The duration of hypnotic effect and the profile of unwanted effects may be influenced by the alpha (distribution) and beta (elimination) half-lives of the administered drug and any active metabolites formed. When half-lives are long, the drug or metabolite may accumulate during periods of nightly administration and be associated with impairments of cognitive and motor performance during waking hours. If half-lives are short, the drug arid metabolites will be cleared before the next dose is ingested, and carry-over effects related to sedation or CNS depression should be minimal or absent. However, during nightly use and for an extended period, pharmacodynamic tolerance or adaptation to some effects of benzodiazepine hypnotics may develop. If the drug has a very short elimination half-life, it is possible that a relative deficiency (i.e., in relation to the receptor site) may occur at some point in the interval between each night's use. This sequence of events may account for two clinical findings reported to occur after several weeks of nightly use of rapidly eliminated benzodiazepine hypnotics: 1) increased wakefulness during the last third of the night; and 2) the appearance of increased daytime anxiety (see WARNINGS).

Flurazepam is a benzodiazepine with a long half-life.

Rebound Insomnia

A transient syndrome whereby the symptoms that led to treatment with a benzodiazepines recur in an enhanced form, may occur on withdrawal of hypnotic treatment.

Pharmacokinetics

Following oral administration of 15 mg flurazepam hydrochloride to male and female volunteers, measurable concentrations for the parent compound were not detectable. Flurazepam undergoes rapid and pronounced metabolism to two pharmacologically active metabolites, namely hydroxyethyl flurazepam and flurazepam aldehyde. In healthy volunteers, C_max values for the two metabolites were 8.6 and 2.5 ng/mL respectively. They were reached in an average of 1.0 and 1.2 hours, respectively. The mean elimination half-lives for these two metabolites were less than 2.5 hours.

The final active and principal metabolite, desalkyl flurazepam (DAFLZ), appears in the systemic circulation more slowly, with a mean C_max of 14 ng/mL attained an average of 10.6 hours after dosing. The mean elimination half-life of DAFLZ is approximately 75 hours (range 50 to 100 hours). Therefore, multiple-dose therapy with flurazepam leads to the accumulation of DAFLZ.

The half-life of DAFLZ was found to be longer in elderly males than in young males (160 versus 74 hours, p<0.05), but was similar in elderly and young females (120 versus 90 hours, p=N.S.). DAFLZ was extensively bound to plasma protein. The unbound fraction increased with age regardless of sex.

Following 15 days treatment with 15 mg flurazepam once daily, mean steady-state plasma levels of DAFLZ were higher in elderly than in young men (81 and 53 ng/rnL, p<0.05), but were similar in elderly and young women (86 and 85 ng/mL).

More than 50% of the total dose of flurazepam appears in the urine in 24 hours, with eventual urinary excretion accounting for 80% or more of the total dose. The major urinary metabolite is conjugated hydroxyethyl flurazepam. Less than 1% of the dose is excreted in the urine as DAFLZ. Approximately 10% of the total dose of flurazepam appears in the feces.

INDICATIONS AND CLINICAL USE

Sleep disturbance may be the presenting manifestation of a physical and/or psychiatric disorder. Consequently, a decision to initiate symptomatic treatment of insomnia should only be made after the patient has been carefully evaluated.

Flurazepam (flurazepam hydrochloride) is indicated for the symptomatic relief of transient and short-term insomnia characterized by difficulty in falling asleep, frequent nocturnal awakenings and/or early morning awakening.

Treatment with Flurazepam should usually not exceed 7-10 consecutive days. Use for more than 2-3 consecutive weeks requires complete re-evaluation of the patient. Prescriptions for

Flurazepam should be written for short-term use (7-10 days) and it should not be prescribed in quantities exceeding a one-month supply.

The use of hypnotics should be restricted for insomnia where disturbed sleep results in impaired daytime functioning.

CONTRAINDICATIONS

Flurazepam (flurazepam hydrochloride) is contraindicated in patients with known hypersensitivity to benzodiazepines, or any component of its formulation, and in those with severe impairment of respiratory function, e.g., significant sleep apnea syndrome.

Flurazepam is contraindicated in patients who have myasthenia gravis or severe hepatic insufficiency.

WARNINGS

General: Benzodiazepines should be used with extreme caution in patients with a history of alcohol abuse.

The smallest possible effective dose should be prescribed for elderly patients. Inappropriate, heavy sedation in the elderly, may result in accidental events/falls.

The failure of insomnia to remit after 7-10 days of treatment may indicate the presence of a primary psychiatric and/or medical illness or the presence of sleep- state misperception.

Worsening of insomnia or the emergence of new abnormalities of thinking or behaviour may be the consequence of an unrecognized psychiatric or physical disorder. These have also been reported to occur in association with the use of drugs that act at the benzodiazepine receptors.

Flurazepam (flurazepam hydrochloride) should be used with caution in patients who in the past manifested paradoxical reactions to alcohol and/or sedative medications.

Pregnancy: The use of flurazepam (flurazepam hydrochloride) during pregnancy is not recommended. Benzodiazepines may cause fetal damage when administered during pregnancy. During the first trimester of pregnancy, several studies have suggested an increased risk of congenital malformations associated with the use of benzodiazepines. During the last weeks of pregnancy, ingestion of therapeutic doses of a benzodiazepine hypnotic has resulted in neonatal CNS depression due to transplacental distribution. If Flurazepam is prescribed to women of childbearing potential, the patient should be warned of the potential risk to a fetus and advised to consult her physician regarding the discontinuation of the drug if she intends to become pregnant or suspects that she might be pregnant.

Memory disturbance: Anterograde amnesia of varying severity has been reported following therapeutic doses of benzodiazepines. The event is rare with flurazepam hydrochloride. Anterograde amnesia is a dose-related phenomenon and elderly subjects may be at particular risk.

Cases of transient global amnesia and "traveller's amnesia" have also been reported in association with benzodiazepines, the latter in individuals who have taken benzodiazepines, often in the middle of the night, to induce sleep while travelling. Transient global amnesia and traveller’s amnesia are unpredictable and not necessarily dose-related phenomena. Patients should be warned not to take Flurazepam (flurazepam hydrochloride) under circumstances in which a full night's sleep and clearance of the drug from the body are not possible before they need again to resume full activity.

Abnormal thinking and psychotic behavioural changes have been reported to occur in association with the use of benzodiazepines including flurazepam hydrochloride, although rarely. Some of the changes may be characterized by decreased inhibition, e.g., aggressiveness or extroversion that seem excessive, similar to that seen with alcohol and other CNS depressants (e.g., sedative/hypnotics). Particular caution is warranted in patients with a history of violent behaviour and a history of unusual reactions to sedatives including alcohol and the benzodiazepines. Psychotic behavioural changes that have been reported with benzodiazepines include bizarre behaviour, hallucinations, and depersonalization. Abnormal behaviours associated with the use of benzodiazepines have been reported more with chronic use and/or high doses but they may occur during the acute, maintenance or withdrawal phases of treatment.

It can rarely be determined with certainty whether a particular instance of abnormal behaviours listed above is drug induced, spontaneous in origin, or a result of an underlying psychiatric disorder. Nevertheless, the emergence of any new behavioural sign or symptom of concern requires careful and immediate evaluation.

Confusion: The benzodiazepines affect mental efficiency, e.g., concentration, attention and vigilance. The risk of contusion is in greater in the elderly and in patients with cerebral impairment.

Anxiety. Restlessness: An increase daytime anxiety and/or restlessness have been observed during treatment with short half-life benzodiazepines although the syndrome can apply on occasion to drugs with longer elimination half-lives as well. Flurazepam has a long half-life.

Depression: Caution should be exercised if flurazepam (flurazepam hydrochloride) is prescribed to patients with signs or symptoms of depression that could be intensified by hypnotic drugs. The potential for self-harm (e.g., intentional overdose) is high in patients with depression and thus, the least amount of drug that is feasible should be available to them at any one time.

Complex Sleep-related Behaviours: Complex sleep-related behaviours such as “sleep-driving” (i.e., driving while not fully awake after ingestion of a sedative-hypnotic, with amnesia for the event) have been reported in patients who have taken flurazepam hydrochloride. Other potentially dangerous behaviours have been reported in patients who got out of bed after taking a sedative-hypnotic and were not fully awake, including preparing and eating food, making phone calls, leaving the house, etc. As with “sleep-driving”, patients usually do not remember these events. The use of alcohol and other CNS-depressants with flurazepam hydrochloride appears to increase the risk of such behaviours, as does the use of flurazepam hydrochloride at doses exceeding the maximum recommended dose. Flurazepam hydrochloride is not to be taken with alcohol. Caution is needed with concomitant use of other CNS depressant drugs. Due to the risk to the patient and the community, discontinuation of flurazepam hydrochloride should be strongly considered for patients who report any such sleep-related behaviours.

Severe Anaphylactic and Anaphylactoid Reactions: Rare cases of angioedema involving the tongue, glottis or larynx have been reported in patients after taking the first or subsequent doses of sedative-hypnotics, including flurazepam hydrochloride. Some patients have had additional symptoms such as dyspnea, throat closing or nausea and vomiting that suggest anaphylaxis. Some patients have required medical therapy in the emergency department. If angioedema involves the throat, glottis or larynx, airway obstruction may occur and be fatal. Patients who develop angioedema after treatment with flurazepam hydrochloride should not be rechallenged with the drug.

PRECAUTIONS

Drug Interactions: Flurazepam (flurazepam hydrochloride) may produce additive CNS depressant effects when co-administered with alcohol, sedative antihistamines, narcotic analgesics, anticonvulsants, or psychotropic medications which themselves can produce CNS depression.

Compounds which inhibit certain hepatic enzymes (particularly cytochrome P450) may enhance the activity of benzodiazepines. Examples include cimetidine or erythromycin.

Drug Abuse Dependence and Withdrawal: Withdrawal symptoms, similar in character to those noted with barbiturates and alcohol (convulsions, tremor, abdominal and muscle cramps, vomiting, sweating, dysphoria, perceptual disturbances and insomnia) have occurred following abrupt discontinuations of benzodiazepines, and may follow the discontinuation of flurazepam hydrochloride. The more severe symptoms are usually associated with higher dosages and longer usage, although patients given therapeutic dosages for as few as 1-2 weeks can also have withdrawal symptoms including daytime anxiety between nightly doses. Consequently, abrupt discontinuation should be avoided and a gradual dosage tapering schedule is recommended in any patient taking more than the lowest dose for more than a few weeks. The recommendation for tapering is particularly important in patients with a history of seizures.

The risk of dependence is increased in patients with a history of alcoholism, drug abuse, or in patients with marked personality disorders. Caution must be exercised in administering Flurazepam (flurazepam hydrochloride) to these individuals.

As with all hypnotics, repeat prescriptions should be limited to those who are under medical supervision.

Patients with Specific Conditions: Flurazepam (flurazepam hydrochloride) should be given with caution to patients with impaired hepatic or renal function. Respiratory depression has been reported in patients with compromised respiratory function.

Patients Requiring Mental Alertness: Because of Flurazepam’s (flurazepam hydrochloride) CNS depressant effect, patients receiving the drug should be cautioned against engaging in hazardous occupations requiring complete mental alertness such as operating machinery or driving a motor vehicle. For the same reason, patients should be warned against the concomitant ingestion of Flurazepam and alcohol or CNS- depressant drugs.

Use in Pregnancy: For teratogenic effects see WARNINGS. Non-teratogenic effects: a child born to a mother who is on benzodiazepines may be at risk for withdrawal symptoms from the drug during the postnatal period. Also, neonatal flaccidity has been reported in an infant born to a mother who had been receiving benzodiazepines.

Use in Nursing Mothers: The safety of Flurazepam (flurazepam hydrochloride) during lactation has not been established. Therefore, its use during nursing is not recommended.

Use in Children: The safety and effectiveness of Flurazepam (flurazepam hydrochloride) in children below the age of 15 have not been established.

Use in the Elderly: Elderly patients are especially susceptible to dose-related adverse effects, such as drowsiness, dizziness, or impaired coordination. Inappropriate, heavy sedation may result in accidental events/falls. Therefore, the lowest possible dose (15 mg) should be used in these subjects.

Laboratory Tests: Should Flurazepam (flurazepam hydrochloride) be used repeatedly, periodic blood counts, liver, and kidney function tests should be performed.

ADVERSE EFFECTS

The most common adverse reactions reported with Flurazepam (flurazepam hydrochloride) are dizziness, drowsiness, lightheadedness, and ataxia. These adverse effects are particularly common in elderly and debilitated patients. (See PRECAUTIONS.) Severe sedation, lethargy, disorientation, and coma, probably indicative of drug intolerance or overdo sage, have been reported.

Isolated instances of headache, heartburn, upset stomach, nausea, vomiting, amnesia, constipation, diarrhea, gastrointestinal pain, nervousness, apprehension, irritability, weakness, palpitations, chest pains, and genito-urinary complaints have been reported. However, in controlled studies, these appeared as often or more often with placebo than with the active drug.

There have also been rare occurrences of leukopenia, granulocytopenia, sweating, flushes, difficulty in focusing, blurred vision, faintness, hypotension, shortness of breath, pruritus, skin rash, dry mouth, bitter taste, excessive salivation, anorexia, euphoria, depression, slurred speech, confusion, restlessness, hallucinations, nightmares, numbed emotions, reduced alertness, changes in libido, inappropriate behavior and elevated SGOT, SGPT, total and direct bilirubins, and alkaline phosphatase. Paradoxical reactions such as excitement, stimulation, agitation, aggressiveness, rages, psychoses and hyperactivity have also been reported in rare instances when using drugs that act at the benzodiazepine receptors.

SYMPTOMS AND TREATMENT OF OVERDOSAGE

Manifestations of Flurazepam (flurazepam hydrochloride) overdosage include somnolence, confusion and coma. Respiration, pulse and blood pressure should be monitored as in all cases of drug overdosage. General supportive measures should be employed, along with immediate gastric lavage. Intravenous fluids should be administered and an adequate airway maintained. Hypotension and CNS depression may be combated by judicious use of appropriate therapeutic agents. The value of dialysis has not been determined. If excitation occurs in patients following Flurazepam (flurazepam hydrochloride) overdosage, barbiturates should not be used.

As with the management of intentional overdosage with any drug, it should be borne in mind hat multiple agents may have been ingested. The benzodiazepine antagonist, flumazenil ('Anexate'), is a specific antidote in known or suspected benzodiazepine overdose. (For conditions of use see 'Anexate' Product Monograph).

DOSAGE AND ADMINISTRATION

The lowest effective dose of Flurazepam (flurazepam hydrochloride) should be used. Treatment with Flurazepam (flurazepam hydrochloride) should be as short as possible, and should usually not exceed 7-10 consecutive days. Use for more than 2-3 consecutive weeks requires complete re-evaluation of the patient.

Dosage should be individualized for maximal beneficial effects.

Adults: The usual adult dosage is 30 mg before retiring. In some patients, 15 mg may suffice.

Elderly and/or Debilitated Patients: It is recommended that therapy be initiated with 15 mg until individual responses are determined.

PHARMACEUTICAL INFORMATION

Drug Substance

Proper Name: Flurazepam Hydrochloride

Trade Name: Flurazepam

Chemical Name: 7-chloro- 1- [2(diethylamino)ethyl]-5-(0-fluorophenyl)- 1, 3-dihydro-

2H- 1, 4-benzodiazepin-2-one-dihydrochloride

Structural Formula:

Molecular Formula: C₂₁H₂₃CIFN₃0.2HCl

Molecular Weight: 460.81

Description: Flurazepam hydrochloride occurs as an off--white to yellow, nearly odorless, crystalline powder, with a melting point of 190-220°C.

Solubility Soluble 1 in 2 of water, 1 in 4 of alcohol, 1 in 90 of chloroform, 1 of methyl alcohol, and 1 in 69 of isopropyl alcohol; very slightly soluble in ether and petroleum spirit and in chloroform.

Composition In addition to flurazepam hydrochloride, each capsule contains the non-medicinal ingredients lactose, starch, and stearic acid. The capsule shell contains the non-medicinal ingredients gelatin, titanium dioxide, sodium lauryl sulfate, silicon dioxide, FD&C yellow #6 and D&C yellow #10. The 15 mg capsule shell also contains FD&C red #40. The 30 mg capsule shell also contains FD&C yellow #40.

Stability and Storage Recommendations

Keep in a tightly closed, light-resistant container. Store at 15-30°C.

AVAILABILITY OF DOSAGE FORMS

FLURAZEPAM -15 15 mg: Each orange/ivory, size #2 capsule imprinted PRO 15' contains 15 mg flurazepam hydrochloride. Available in bottles of 100 and 1000.

FLURAZEPAM - 30 30 mg: Each red/ivory, size #2 capsule imprinted PRO 30' contains 30 mg flurazepam hydrochloride. Available in bottles of 100 and 1000.

PHARMACOLOGY

In animals, flurazepam hydrochloride has been demonstrated to produce sedative, anticonvulsant, taming, and muscle relaxant effects. At high doses, flurazepam hydrochloride exhibited sedative effects in rats (36 mg/kg), as well as a depressant effect on behaviour in squirrel monkeys (40 mg/kg). Some cardiovascular depressant effects were also observed, but were largely attributed to the central nervous system depressant effects of high doses.

Flurazepam and its metabolites bind with high affinity to mouse brain membranes. In vitro specific binding affinities (Ki) for flurazepam, hydroxyethyl-flurazepam, flurazepam aldehyde and desalkyl-flurazepam were 10.7, 16.2, 10.6, and 0.85 nM, respectively. Flurazepam hydrochloride is rapidly absorbed from the gastrointestinal tract and is rapidly metabolized. Studies in rats with ¹⁴C-labelled flurazepam hydrochloride indicated that the drug is widely distributed throughout body tissues with no excessive accumulation of drug or metabolite in any one tissue.

TOXICOLOGY

The oral LD50 was 870 mg/kg in mice, 1,232 mg/kg in rats and 568 mg/kg in rabbits. Chronic toxicity studies for one year indicated that the tolerated dose is 80 mg/kg/day in the rat and 10 mg/kg/day in the dog.

Effects on Reproduction: A two-cycle reproductive study in rats was carried out at doses of 5 and 50 mg/kg/day of flurazepam hydrochloride. There were no significant teratogenic or other adverse effects related to the drug. In the second series of rat reproductive studies, doses of 3 and 20 mg/kg/day of flurazepam hydrochloride did not induce changes in fertility and general reproductive performance. There were no significant teratogenic effects related to the drug or adverse effects in the perinatal and postnatal study. In another reproductive study in rats at doses of 10, 20, 40 and 80 mg/kg/day, no adverse effects on reproduction and no significant teratological changes were noted.

In rabbits, two sets of teratogenic studies were done. In the first, flurazepam hydrochloride was administered in doses of 5 and 20 mg/kg/day. Twenty-three live litters were obtained in this study. One animal which received 20 mg/kg/day had a litter of nine viable but deformed fetuses. In the second study, the dose of flurazepam hydrochloride was increased to 40 mg/kg/day without the occurrence of abnormalities in all eleven litters. In both studies, there were no significant differences between the control and treated groups in maternal weight, body weight of viable fetuses, fetal body weight and litter size.

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