natgillin/translations-raw huggingface dataset:
De hyppigst indberettede bivirkninger med dødelig udgang omfattede sygdomme i lever og galdeveje, hudsygdomme, almene sygdomme, sygdomme i blod- og lymfesystemet, sygdomme i nervesystemet, gastrointestinale sygdomme samt hjertesygdomme.
The most frequently reported adverse reactions with fatal outcome involved hepatobiliary disorders, skin disorders, general disorders, blood and lymphatic disorders, nervous system disorders, gastrointestinal disorders and cardiac disorders.
Ibuprofen har også vist sig at være mere effektivt som enkeltdosis til behandling af postoperative smerter, og tramadol har samme virkning under disse forhold.
Ibuprofen has also shown to be more effective, as a single dose, in the management of severe postoperative pain; tramadol being equally effective in this setting.
Også i Irland viste analyser i 2009 af yderligere data fra alkohol- og narkotikaforskningsenheden ved det irske sundhedsforskningsorgan (Health Research Board) en betragtelig underrapportering af dødsfald, som var forbundet med lægemidler indeholdende dextropropoxyfen, - femten gange flere dødsfald end tidligere indberettet.
Similarly in Ireland, analysis in 2009 of further data from the Alcohol and Drug Research Unit of the Health Research Board revealed significant under-reporting of deaths associated with dextropropoxyphene-containing products - indicating fatality rates fifteen-fold higher than previously reported.
Mod kroniske smerter har andre kombinationer af paracetamol og et opioid (såsom en fastdosiskombination af paracetamol og kodeinfosfat) eller en kombination af et non-steroidt antiinflammatorisk lægemiddel (NSAID) og et andet opioid end dextropropoxyfen vist sig at være mindst lige så effektivt som den faste kombination af dextropropoxyfen og paracetamol.
In chronic pain, other combinations of paracetamol and an opioid (such as a fixed-dose combination of paracetamol and codeine phosphate), or a combination of a non-steroidal anti-inflammatory drug (NSAID) and an opioid other than dextropropoxyphene have been shown to be at least as effective as the fixed combination of dextropropoxyphene and paracetamol.
På baggrund af den begrænsede virkning og den signifikante risiko for dødelig overdosering (især utilsigtet overdosering) var CHMP af den opfattelse, at benefit/risk-forholdet for lægemidler indeholdende dextropropoxyfen var negativt.
Based on the limited efficacy and the significant risk of fatal overdose (in particular accidental overdose), the CHMP was of the opinion that the benefit/risk balance of dextropropoxyphene containing medicinal products was negative.
Undersøgelser i Det Forenede Kongerige viste også fordele ved at trække dextropropoxyfen tilbage fra markedet - med et tydeligt fald i antallet af dødsfald forbundet med dextropropoxyfen, dog uden nogen stigning i antallet af dødsfald som følge af forgiftning med almindelige smertestillende midler.
Also, research in the UK demonstrated the benefits of the withdrawal of dextropropoxyphene from the market - with clear evidence of a fall in number of deaths associated with dextropropoxyphene, but without any rise in mortality from poisoning with other common analgesics.
For den tilsvarende dosis dextropropoxyfen i kombination med paracetamol 650 mg var det påkrævede antal til gavnlig behandling 4,4 (3,5 til 5,6) sammenlignet med placebo, hvilket angiver, at dette har en bedre virkning.
For the equivalent dose of dextropropoxyphene combined with paracetamol 650 mg the NNT was 4.4 (3.5 to 5.6) when compared with placebo, indicating higher efficacy.
De risikonedsættende foranstaltninger, som blev foreslået af indehaverne af markedsføringstilladelse, bestod bl.a. i begrænsning af brugen af produktet (dvs. ændringer i produktresuméerne for at begrænse patientpopulationen, mindre pakningsstørrelser), ændring af doseringen (f.eks. en mindre dosering til ældre) samt tilføjelse at yderligere sikkerhedsadvarsler (f.eks. om brug sammen med alkohol, afhængighed og tolerance, brug i kombination med andre centralt virkende smertestillende midler, og overdosering hos børn).
Risk Minimisation measures proposed by the MAHs included restriction of the use of the product (i.e. changes in SPC to restrict the population; pack size reduction), modification of the posology (e.g. reduction of posology in elderly population) and addition of further safety warnings (e.g. on concomitant use with alcohol, dependence and tolerance, combination with other central acting analgesics and overdose in children).
Bortset fra de yderligere advarsler og mere omfattende kontraindikationer, som blev foreslået af indehaverne af markedsføringstilladelse, afspejlede forslagene om ændring af produktresuméer og indlægssedler - f.eks. med hensyn til indikationer - de eksisterende forskelle i Europa, og de var ofte ukonsekvente hver for sig.
Apart from the strengthened warnings, and more extensive contra-indications, proposed by several MAHs, the other proposals for changes in the SPCs and PLs - for example, in relation to indication - reflected the existing variations across Europe and were often not internally consistent.
De tilgængelige data om virkningen er begrænsede som følge af metodologiske mangler, såsom manglende beregning af prøvestørrelsen i størstedelen af de dobbeltblindede undersøgelser af akutte smerter, og manglende data om den langsigtede virkning til at understøtte anvendelsen af den faste kombination af dextropropoxyfen og paracetamol som længevarende behandling.
Available efficacy data are limited due to methodological shortcomings such as the absence of a sample size calculation in the majority of the double-blind studies in acute pain and the lack of long term efficacy data to support the use of the fixed combination of dextropropoxyphene and paracetamol as a prolonged treatment.
Tilstedeværelsen af en parenteral formulering kan ses som en yderligere terapeutisk mulighed, da det formentlig vil reducere risikoen for utilsigtet overdosering (af patienter, der tager mere, fordi virkningen udebliver) og for tilsigtet overdosering (afhængig af, hvor forsyningerne blev opbevaret).
The availability of a parenteral formulation might be viewed as providing a further therapeutic option, since it would arguably reduce the risk of an accidental overdose (by the patient taking more, because of lack of efficacy) and of intentional overdose (depending on where supplies were held).
- Dokumentation for en patientpopulation, i hvilken benefit/risk-forholdet for parenterale lægemidler indeholdende dextropropoxyfen er positivt.
- Evidence of a patient population in which the benefit-risk balance of parenteral dextropropoxyphene medicinal products is positive.
Set i lyset af den komplekse sammenhæng, hvori de dødelige overdoseringer fandt sted under normale anvendelsesbetingelser, samt det snævre terapeutiske indeks og risikoen for hurtig død, mente CHMP ikke, at de ovennævnte foreslåede tiltag for at mindske risikoen, såsom indsnævring af indikationen, reduktion af pakningernes størrelse og/eller flere sikkerhedsadvarsler og kontraindikationer (ud over dem, der findes i produktinformationen), ville nedbringe risikoen til et acceptabelt niveau.
In view of the complex context in which cases of fatal overdose occurred under normal conditions of use and in view of the narrow therapeutic index and the potential for rapid death, the CHMP was of the opinion that the above proposed risk minimisation activities of narrowing the indication, reducing the pack sizes and/or introducing further safety warnings and contraindications (including those beyond the Product Information) would not be able to reduce the risks to an acceptable level.
Manglen på data om den langsigtede virkning gjorde det desuden umuligt at træffe endegyldige konklusioner om virkningen af lægemidler indeholdende dextropropoxyfen som langtidsbehandling.
Furthermore, the lack of long term efficacy data did not allow any definite conclusions to be drawn on the efficacy of the dextropropoxyphene medicinal products as a long-term treatment.
CHMP vurderede de oplysninger, der var blevet indsendt af indehaverne af markedsføringstilladelsen som svar på de ovennævnte betænkeligheder, samt de tilgængelige data fra medlemsstaterne om forgiftninger, hvor dextropropoxyfen indgik, og undersøgelser af mistænkelige dødsfald i de pågældende lande.
The CHMP reviewed the data submitted by the MAHs to address the above-mentioned concerns as well as the available data from Member States in relation to drug poisoning that involves dextropropoxyphene and the investigation of suspicious deaths in their countries.
CHMP behandlede desuden andre kendte risici forbundet med brugen af parenterale opioider, f.eks. risiko for misbrug og afhængighed.
In addition, the CHMP considered other known risks associated with the use of parenteral opioids such as the risk of abuse and dependence.
De største betænkeligheder vedrørende dextropropoxyfen er dog, at det har et meget snævert terapeutisk indeks under normale anvendelsesbetingelser: efter overdosis, viser hjertearytmier (som ikke kan standses med naloxon) og bivirkninger ved opioider (som f.eks. respirationshæmning) sig hurtigt og er ofte dødelige - det er dokumenteret, at dødeligheden er højere end eksempelvis for tricykliske antidepressive midler.
However, the key safety concern with dextropropoxyphene is that it has a very narrow therapeutic index under normal conditions of use: following overdose, cardiac arrhythmias (which cannot be reversed using naloxone) and opioid side effects (such as respiratory depression) are rapid in onset and often fatal - there is evidence that the case fatality rate is higher than, for example, for tricyclic antidepressants.
CHMP vurderede dog, at parenterale opioider medfører yderligere betydelige risici i sig selv, herunder misbrug/afhængighed og diversion, hvilket også er et stort problem.
However, the CHMP considered that parenteral opioids carry further significant risks in themselves, such as abuse/dependence and diversion which are also of major concern.
Selv om de tilgængelige metaanalyser hovedsageligt omfattede enkeltdosisundersøgelser, gav disse data alligevel yderligere indsigt i virkningen af lægemidler indeholdende dextropropoxyfen.
Although available meta-analyses mostly included single dose studies, these data also provided further insights in the efficacy of the dextropropoxyphene containing medicinal products.
De tilgængelige data viste kun en begrænset virkning af lægemidler indeholdende dextropropoxyfen til symptomatisk behandling af smerter.
Available data showed only limited efficacy of the dextropropoxyphene medicinal products in the symptomatic treatment of pain.
Selv om en parenteral formulering af dextropropoxyfen kan ses som en yderligere terapeutisk mulighed, medfører parenterale opioider yderligere betydelige risici i sig selv, såsom misbrug/afhængighed og diversion, hvilket det er vanskeligt at retfærdiggøre i dette tilfælde på grund af manglen på dokumentation for virkningen.
Though a parenteral formulation of dextropropoxyphene might be viewed as providing a further therapeutic option, parenteral opioids carry further significant risks in themselves, such as abuse/dependence and diversion, which would appear difficult to justify in this instance given the lack of evidence of efficacy.
For at ophæve suspenderingen skal indehaverne af markedsføringstilladelse fremlægge dokumentation for en patientpopulation, i hvilken benefit/risk-forholdet for parenterale lægemidler indeholdende dextropropoxyfen er positivt.
For the suspension to be lifted, the Marketing Authorisation Holders would need to provide evidence of a patient population in which the benefit-risk balance of parenteral dextropropoxyphene medicinal products is positive.
Navnlig viste mere omfattende data fra Frankrig om dødstal på nationalt plan, især retsvidenskabelige toksikologiske resultater, at der skete langt flere dødsfald i forbindelse med brugen af lægemidler indeholdende dextropropoxyfen end før antaget.
In particular, more comprehensive mortality data at a national level from France, notably forensic toxicology results, provided evidence of a significantly greater number of deaths associated with the use of dextropropoxyphene-containing products than had previously been estimated.
Udvalget bemærkede, at risikoen er begrænset for de parenterale lægemidler indeholdende dextropropoxyfen, da de indgives i hospitalsregi (af sundhedspersonalet), og at disse lægemidler er klassificeret som receptpligtige narkotika (i den medlemsstat, hvor lægemidlet er godkendt).
The Committee noted that this risk is limited for the parenteral dextropropoxyphene medicinal products, given the administration under hospital setting (given by healthcare professionals) and the classification of these medicinal products as narcotic prescription (in the Member State where the product is authorised).
En betragtelig del af de dødelige overdoser under normale anvendelsesbetingelser til den godkendte indikation smerter er utilsigtede - og disse tilfælde alene har en væsentlig indvirkning på folkesundheden.
A substantial proportion of the fatal overdoses are accidental - occurring under normal conditions of use, for the licensed indication of painand there is a significant public health impact in relation to these cases alone.
Selv om spontane rapporter antydede, at sikkerhedsrisikoen i forbindelse med overdosering ikke var signifikant, bekræftede andre mere udførlige data, især fra retsmedicinske centre og nationale dødsstatistikker, at risikoen for utilsigtet dødelig overdosering, der kan sammenkædes med lægemidler indeholdende dextropropoxyfen, er et stort problem, hovedsageligt på grund af deres snævre terapeutiske indeks og høje dødsrate.
Although spontaneous reporting suggested that the safety signal concerning the overdose was not significant, other more complete data, particularly from forensic centres and national mortality statistics confirmed that the risk of accidental fatal overdose under normal conditions of use associated with dextropropoxyphene containing products is of major concern, mainly due to their narrow therapeutic index and high case fatality.
Efter en gennemgang af den detaljerede skriftlige begrundelse for revurdering og den mundtlige redegørelse fra indehaverne af markedsføringstilladelse fandt CHMP, at udformningen af den foreslåede kliniske undersøgelse til påvisning af, at kombinationen af dextropropoxyfen og paracetamol havde bedre virkning end paracetamol alene, var mangelfuld, og selv en veludformet undersøgelse ville ikke ændre benefit/risk-forholdet for lægemidler indeholdende dextropropoxyfen i lyset af dets snævre terapeutiske indeks.
Having considered the detailed grounds for re-examination provided by the group of MAHs in writing and in an oral explanation, the CHMP considered that the design of the proposed clinical study to demonstrate the superior efficacy for combination of dextropropoxyphene and paracetamol versus paracetamol alone was flawed, and even a well-designed study would not change the benefit-risk balance of the dextropropoxyphene medicinal products in view of the narrow therapeutic index.
Nogle patienter oplever, at disse lægemidler er effektive til smertebehandling, men resultater fra kliniske undersøgelser giver ikke dokumentation for større virkning af dextropropoxyfen alene eller i kombination med paracetamol sammenlignet med normale terapeutiske doser af simple smertestillende lægemidler.
While some patients find these products helpful in managing pain, results from clinical trials do not provide evidence for the superior efficacy of dextropropoxyphene alone or in combination with paracetamol, when compared with normal therapeutic doses of simple analgesics.
Selvom der er risiko for en dødelig overdosis, fandt CHMP, at denne er begrænset for parenterale lægemidler indeholdende dextropropoxyfen, da de indgives i hospitalsregi (af sundhedspersonalet), at disse lægemidler er klassificeret som receptpligtige narkotika (i den medlemsstat, hvor lægemidlet er godkendt), og da der savnes dokumentation for dødelig overdosering, navnlig utilsigtet overdosering.
Whilst there is a risk of fatal overdose, the CHMP considered that it is limited for the parenteral dextropropoxyphene medicinal products, given the administration under hospital setting (given by healthcare professionals) and the classification of these medicinal products as narcotic prescription (in the Member State where the product is authorised) and the lack of evidence of fatal overdose particularly of accidental overdose.
CHMP noterede sig det snævre terapeutiske indeks for lægemidler indeholdende dextropropoxyfen.
However, the CHMP took note of the narrow therapeutic index of dextropropoxyphen containing products.
De forskellige tal, der fremgår af datakilderne (spontane rapporter, retsmedicinske centre, giftinformationscentraler, nationale dødsstatistikker), viste generelt et betydeligt antal af dødsfald, hvor dextropropoxyfen fandtes på toksisk niveau.
The different figures provided by the available data sources (spontaneous reports, forensic and poison centres, national mortality statistics) showed overall a significant number of deaths in which dextropropoxyphene is present at toxic levels.
Efter at have gennemgået de tilgængelige data vurderede CHMP, at de forskellige tal, der fremgår af datakilderne (spontane rapporter, retsmedicinske centre, giftinformationscentraler, nationale dødsstatistikker), generelt viste et betydeligt antal af dødsfald, hvor dextropropoxyfen fandtes på toksisk niveau.
After reviewing all the available data, the CHMP considered that the different figures provided by the data sources (spontaneous reports, forensic and poison centres, national mortality statistics) showed overall a significant number of deaths in which dextropropoxyphene is present at toxic levels.
CHMP mente desuden, at de indsamlede data fra de nationale giftinformationscentraler har begrænsninger i denne situation, eftersom dextropropoxyfen kan være dødbringende efter ekstremt kort tid (under en time).
The CHMP also considered that data collected from national poison centres have limitations in this situation as dextropropoxyphene can cause death extremely rapidly (in under an hour); if a patient dies before reaching medical attention, the poisons centre is unlikely to be contacted.
Anbefalede CHMP, efter at have overvejet sagen, som den fremstår i den vedlagte vurderingsrapport, suspendering af markedsføringstilladelserne for alle de parenterale lægemidler, der er nævnt i bilag I, hvilket skal ske inden for en periode på 15 måneder fra Kommissionens afgørelse, så sundhedspersonalet kan forberede sig på et eventuelt skift til alternative behandlinger.
The CHMP, having considered the matter as set out in the appended referral assessment report recommended the suspension of the Marketing Authorisations for all parenteral medicinal products referred to in Annex I to be effected within 15 months of the Commission Decision in order to allow healthcare professionals to prepare for a potential switch to using alternatives.. For the suspension to be lifted the Marketing Authorisation Holders would need to provide evidence of a patient population in which the benefit-risk balance of parenteral dextropropoxyphene medicinal products is positive.
- CHMP fandt ikke, at virkningen af parenterale lægemidler indeholdende dextropropoxyfen var fastslået.
- The Committee considered that the efficacy of parenteral dextropropoxyphene containing medicinal products has not been established;
Derfor stammer de mest pålidelige data fra retsmedicinske analyser og nationale dødsstatistikker, og en komplet gennemgang af de dødelige overdoser, der kan sammenkædes med dextropropoxyfen (alene og i kombination med paracetamol/koffein), understøttede den vigtigste betænkelighed ved den dødelige toksicitet ved lægemidler indeholdende dextropropoxyfen under normale anvendelsesbetingelser på grund af deres snævre terapeutiske indeks.
Because of this, the most reliable data come from forensic analysis and national mortality statistics, and complete review of the fatal overdoses associated with dextropropoxyphene (alone and in combination with paracetamol/caffeine)
Der foreligger dog ikke tilstrækkelig dokumentation fra kliniske undersøgelser om, at virkningen af kombinationen af dextropropoxyfen og paracetamol skulle være bedre end ved normale terapeutiske doser af paracetamol.
However, there is no clear evidence from clinical trials of superiority of efficacy of the combination of dextropropoxyphene and paracetamol compared with normal therapeutic doses of paracetamol alone, the trials which have suggested superiority to paracetamol alone have used sub-therapeutic doses of paracetamol.
Da virkningen af parenterale lægemidler indeholdende dextropropoxyfen ikke er fastslået, konkluderede CHMP dog, at benefit/risk-forholdet for parenterale lægemidler indeholdende dextropropoxyfen var negativt, og anbefalede suspendering af markedsføringstilladelserne inden for en periode på 15 måneder fra Kommissionens afgørelse, så sundhedspersonalet kunne forberede sig på et eventuelt skift til alternative behandlinger.
Nevertheless, the CHMP also took the well-established narrow therapeutic index into account, as well as other known risks associated with the use of parenteral opioids and potentially associated with the use of parenteral dextropropoxyphene such as abuse and dependence and given that the efficacy of parenteral dextropropoxyphene containing medicinal products has not been established, the CHMP concluded that the benefit-risk balance for the parenteral dextropropoxyphene containing medicinal products was negative and recommended the suspension of the Marketing Authorisations to be effected within 15 months of the Commission Decision to allow healthcare professionals to prepare for a potential switch to using alternatives.
CHMP konkluderede derfor ved flertalsafgørelse, at benefit/risk-forholdet for lægemidler indeholdende dextropropoxyfen er negativt, og at dets udtalelse af 25. juni 2009 ikke skulle revideres for orale/rektale lægemidler indeholdende dextropropoxyfen,
Therefore, the CHMP concluded by majority that the benefit-risk balance of dextropropoxyphene containing medicinal products is negative and that its Opinion of 25 June 2009 should not be revised for oral/rectal dextropropoxyphene containing medicinal products and recommended the withdrawal of the Marketing Authorisations to be effective within the next 15 months of the Commission Decision in order to allow switching patients to safer alternatives, considering the extensive clinical use of dextropropoxyphene containing medicinal products and the wide patient exposure in some Member States.
MA (EU)-nummer (Sær)navn Styrke Lægemiddelform Administrationsvej Indre emballage
MA (EU) number (Invented) name Strength Pharmaceutical Form
EU/1/15/1054/002 Cinacalcet Mylan 30 mg Filmovertrukket tablet Til oral anvendelse flaske (HDPE)
Immediate Packaging Pack size bottle (HDPE)
ATCvet-kode: QI07AI08.
ATC vet code: QI07AI08.
MARKEDSFØRINGSTILLADELSENS NUMMER (NUMRE) EU/2/14/172/001
MARKETING AUTHORISATION NUMBER(S) EU/2/14/172/001
Dato for seneste fornyelse af markedsføringstilladelse: 11/04/2019.
Date of last renewal: 11/04/2019.
Farmakoterapeutisk gruppe: Immunologiske midler til canidae, levende virusvacciner og inaktiverede bakterievacciner.
Pharmacotherapeutic group: Immunologicals for canidae, live viral and inactivated bacterial vaccines.