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Public Assessment Report
Decentralised Procedure
CO-AMOXICLAV 250MG/125MG FILM-COATED TABLETS
CO-AMOXICLAV 500MG/125MG FILM-COATED TABLETS
(amoxicillin trihydrate, potassium clavulanate,
diluted)
Procedure No: UK/H/3244/001-2/DC
UK Licence No: PL 25298/0007-8
BROWN AND BURK UK LIMITED
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LAY SUMMARY
Co-amoxiclav 250mg/125mg film-coated Tablets
Co-amoxiclav 500mg/125mg film-coated Tablets
(amoxicillin trihydrate, potassium clavulanate)
This is a summary of the Public Assessment Report (PAR) for Co-amoxiclav 250mg/125mg film-
coated Tablets (UK/H/3244/001/DC; PL 25298/0007) and Co-amoxiclav 500mg/125mg film-coated
Tablets (UK/H/3244/002/DC; PL 25298/0008). It explains how Co-amoxiclav 250mg/125mg film-
coated Tablets and Co-amoxiclav 500mg/125mg film-coated Tablets were assessed and their
authorisations recommended, as well as their conditions of use. It is not intended to provide practical
advice on how to use Co-amoxiclav 250mg/125mg film-coated Tablets and Co-amoxiclav
500mg/125mg film-coated Tablets.
The product may be referred to as Co-amoxiclav Tablets throughout the remainder of this lay
summary.
For practical information about using Co-amoxiclav Tablets, patients should read the package leaflet or
contact their doctor or pharmacist.
What are Co-amoxiclav Tablets and what are they used for?
Co-amoxiclav Tablets are generic medicines. This means that Co-amoxiclav Tablets are similar to
‘reference medicines’ already authorised in the European Union (EU) called Augmentin 375mg and
625mg Film-coated Tablets (Beecham Group plc).
Co-amoxiclav Tablets are used in adults and children to treat the following infections:
Co-amoxiclav 250mg/125mg film-coated Tablets
• Sinus infection
• Urinary tract infections
• Skin infections
• Dental infections
Co-amoxiclav 500mg/125mg film-coated Tablets
• Middle ear and sinus infections
• Respiratory tract infections
• Urinary tract infections
• Skin and soft tissue infections including dental infections
• Bone and joint infections
How do Co-amoxiclav Tablets work?
Co-amoxiclav Tablets belongs to a group of medicines known as antibiotics. Co-amoxiclav Tablets
works by killing bacteria that cause infections. Co-amoxiclav Tablets contains two active ingredients,
amoxicillin (as amoxicillin trihydrate) and clavulanic acid (as potassium clavulanate, diluted).
Amoxicillin belongs to a group of medicines called “penicillins” that can sometimes be stopped from
working (made inactive). The other active component (clavulanic acid) stops this from happening.
How are Co-amoxiclav Tablets used?
The pharmaceutical form of this medicine is a tablet and the route of administration is oral (by mouth).
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The patient should always take this medicine exactly as their doctor or pharmacist has told them. The
patient should check with their doctor or pharmacist if they are not sure.
Co-amoxiclav Tablets should be taken with a meal. The tablets should be swallowed whole with a
glass of water. The doses should be evenly spaced out during the day, at least 4 hours apart. The patent
should not take 2 doses in 1 hour.
This medicine should not be taken for more than 2 weeks. If the patient still feels unwell, they should
go back to see the doctor.
Adults and children weighing 40 kg and over
250 mg/125 mg film-coated tablets:
The usual dose is 1 tablet three times a day
500 mg/125 mg film-coated tablets:
The usual dose is 1 tablet three times a day
Children weighing less than 40 kg
Co-amoxiclav Tablets are not recommended.
Children aged 6 years or less should preferably be treated with amoxicillin/clavulanic acid oral
suspension or sachets.
Ask the doctor or pharmacist for advice when giving Co-amoxiclav tablets to children weighing less
than 40 kg. The tablets are not suitable for children weighing less than 25 kg.
Patients with kidney and liver problems
• If the patient has kidney problems the dose might be changed. A different strength or a different
medicine may be chosen by the doctor.
• If the patient has liver problems, they may have more frequent blood tests to check how the liver is
working.
For further information on how Co-amoxiclav Tablets are used, refer to the package leaflet and
Summaries of Product Characteristics available on the Medicines and Healthcare products Regulatory
Agency (MHRA) website.
This medicine can only be obtained with a prescription.
What benefits of Co-amoxiclav Tablets have been shown in studies?
Because Co-amoxiclav Tablets are generic medicines, studies in patients have been limited to tests to
determine that they are bioequivalent to the reference product, Augmentin 375mg and 625mg Film-
coated Tablets (Beecham Group plc). Two medicines are bioequivalent when they produce the same
levels of the active substance in the body.
What are the possible side effects of Co-amoxiclav Tablets?
Because Co-amoxiclav Tablets are generic medicines and are bioequivalent to the reference medicines
Augmentin 375mg and 625mg Film-coated Tablets (Beecham Group plc) their benefits and possible
side effects are taken as being the same as those for the reference products.
For the full list of all side effects reported with Co-amoxiclav Tablets, see section 4 of the package
leaflet available on the MHRA website.
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Why were Co-amoxiclav Tablets approved?
It was concluded that, in accordance with EU requirements, Co-amoxiclav Tablets have been shown to
have comparable quality and to be bioequivalent to the reference medicines; Augmentin 375mg and
625mg Film-coated Tablets (Beecham Group plc). Therefore, the MHRA decided that, as for
Augmentin 375mg and 625mg Film-coated Tablets (Beecham Group plc); the benefits are greater than
the risks and recommended that they can be approved for use.
What measures are being taken to ensure the safe and effective use of Co-amoxiclav Tablets?
Safety information has been included in the Summaries of Product Characteristics (SmPCs) and the
package leaflet for Co-amoxiclav Tablets including the appropriate precautions to be followed by
healthcare professionals and patients.
Known side effects are continuously monitored. Furthermore new safety signals reported by
patients/healthcare professionals will be monitored/reviewed continuously. Other information about Co-amoxiclav Tablets
The UK, Ireland and Sweden granted Marketing Authorisations to Co-amoxiclav Tablets on 01
December 2011. Subsequently followed by a national phase, Marketing Authorisations were granted in
the UK on 23 December 2011.
The full PAR for Co-amoxiclav Tablets follows this summary.
This summary was last updated in January 2019.
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TABLE OF CONTENTS
I INTRODUCTION 6 II QUALITY ASPECTS 7
III NON-CLINICAL ASPECTS 9
IV CLINICAL ASPECTS 9
V User consultation 11 VI Overall conclusion, benefit/risk assessment and recommendation 11 Table of content of the PAR update for MRP and DCP 17
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I INTRODUCTION
Based on the review of the data on quality, safety and efficacy, the RMS considered that the
applications for Co-amoxiclav 250mg/125mg and 500mg/125mg Film-coated Tablets
(PL 25298/0007-8; UK/H/3244/001-2/DC) could be approved. The products are
prescription-only medicines for the treatment of the following bacterial infections in adults
and children:
Co-amoxiclav 250mg/125mg Film-coated Tablets
• Acute bacterial sinusitis (adequately diagnosed)
• Cystitis
• Pyelonephritis
• Cellulitis
• Animal bites
• Severe dental abscess with spreading cellulitis.
Co-amoxiclav 500mg/125mg Film-coated Tablets
• Acute bacterial sinusitis (adequately diagnosed)
• Acute otitis media
• Acute exacerbations of chronic bronchitis (adequately diagnosed)
• Community acquired pneumonia
• Cystitis
• Pyelonephritis
• Skin and soft tissue infections in particular cellulitis, animal bites, severe dental abscess
with spreading cellulitis.
• Bone and joint infections, in particular osteomyelitis
These are applications made under the decentralised procedure (DCP), with the UK as RMS,
and Ireland and Sweden as CMS. The applications were submitted according to Article 10.1
of 2001/83 EC, as amended, claiming to be generic medicinal products of Augmentin 375mg
and 625mg Film-coated Tablets (Beecham Group plc), which were originally granted
Marketing Authorisations in 1981 and 1991, respectively.
Amoxicillin is a member of the penicillin family. The penicillin nucleus consists of a
thiazolidine ring connected to a β-lactam ring, to which a side-chain is attached. The side-
chain determines most of the pharmacological and antibacterial properties of the penicillin in
question. In the case of amoxicillin the benzyl ring in the side chain extends the range of
antimicrobial activity into the Gram-negative bacteria. Amoxicillin kills bacteria by
interfering with the synthesis of the bacterial cell wall. As a result the bacterial cell wall is
weakened, the cell swells and then ruptures. Amoxicillin is readily hydrolysed by the
staphylococcal penicillinase. Its spectrum of activity is extended by administration with the
β-lactamase inhibitor clavulanic acid. Clavulanate by itself has little antibacterial activity.
No new non-clinical studies were conducted, which is acceptable given that the applications
were generics of originator products which have been licensed for over 10 years. The
bioequivalence studies were carried out in accordance with Good Clinical Practice (GCP).
With the exception of the bioequivalence study, no new clinical studies were conducted,
which is acceptable given that the applications were based on being generic medicinal
products of originator products that have been licensed for over 10 years.
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The RMS has been assured that acceptable standards of GMP are in place for these product
types at all sites responsible for the manufacture and assembly of these products.
II. QUALITY ASPECTS
II.1. Introduction
Both strengths of tablets are packaged in aluminium blister strips, which are then enclosed in
a cardboard box. Pack sizes for both strengths are 4, 5, 6, 7, 8, 10, 12, 14, 15, 16, 20, 21, 25,
30, 35, 40, 50, 100 and 500 film-coated tablets. Not all pack sizes are to be marketed.
However, the Marketing Authorisation Holder has committed to submitting the mock-ups for
any pack size to the relevant regulatory authorities for approval before marketing.
Satisfactory specifications and Certificates of Analysis have been provided for all packaging
components. All primary packaging complies with the current European regulations
concerning materials in contact with food.
II.2. Drug substance
ACTIVE SUBSTANCE – AMOXICILLIN TRIHYDRATE
INN: Amoxicillin trihydrate
Chemical Name: (2S,5R,6R)-6-[[(2R)-2-Amino-2-(4-hydroxyphenyl)acetyl]-
amino]-3,3-dimethyl-7-oxo-4-thia-1-azabicyclo [3.2.0]
heptane-2-carboxylic acid Trihydrate
OR
4-Thia-1-azabicyclo[3.2.0]heptane-2-carboxylic acid,6-
[[amino(4-hydroxyphenyl)acetyl]amino-3,3-dimethyl-7-
oxo,trihydrate 2S-[2α,[5α,6β (S*)]]
OR
(2S,5R,6R)-6-[(R)-(-)-2-amino-2-(p-hydroxyphenyl)
acetamido]-3,3-dimethyl-7-oxo-4-thia-1-azabicyclo [3.2.0]
heptane-2-carboxylic acid trihydrate
Molecular Formula: C16H19N3O5S·3H2O
Chemical Structure:
Molecular Weight: 419.4
Appearance: A white or almost white, crystalline powder, slightly soluble in water,
very slightly soluble in ethanol (96 per cent), practically insoluble in
fatty oils, chloroform and ether. It dissolves in dilute acids and dilute
solutions of alkali hydroxides.
Amoxicillin trihydrate is the subject of a European Pharmacopoeia monograph.
All aspects of the manufacture and control of the active substance amoxicillin trihydrate are
covered by a European Directorate for the Quality of Medicines (EDQM) certificate of
suitability.
ACTIVE SUBSTANCE – POTASSIUM CLAVULANATE
INN: Potassium clavulanate
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Chemical Name: Potassium (2R, 3Z, 5R)-3-2 (hydroethylidene)-7-oxo-4-oxa-1-
azabizyclo [3.2.0] heptane-2-carboxylate
Molecular Formula: C8H8KNO5
Chemical Structure:
Molecular Weight: 237.3
Appearance: A white or almost white, crystalline, hygroscopic powder, freely
soluble in water
Potassium clavulanate is the subject of a European Pharmacopoeia monograph.
All aspects of the manufacture and control of the active substance potassium clavulanate are
covered by a European Directorate for the Quality of Medicines (EDQM) certificate of
suitability.
II.3. Medicinal Product
Other Ingredients
Other ingredients consist of pharmaceutical excipients microcrystalline cellulose (E460),
sodium starch glycolate (Type A), colloidal anhydrous silica (E551), magnesium stearate
(E572), titanium dioxide (E171), hypromellose (E464), ethyl cellulose, Talc (E553b)
and polyethylene glycol.
All excipients are controlled to their respective European Pharmacopoeia monograph.
Suitable batch analysis data have been provided for each excipient, showing compliance with
their respective monograph.
None of the excipients is sourced from animal or human origin. No genetically modified
organisms (GMO) have been used in the preparation of these products.
Pharmaceutical Development
The objective of the development programme was to formulate stable, efficacious and
tolerable film-coated tablets containing amoxicillin trihydrate and potassium clavulanate that
can be considered generic medicinal products of Augmentin 375mg and 625mg Film-coated
Tablets (Beecham Group plc).
A satisfactory account of the pharmaceutical development has been provided.
Comparative in vitro dissolution and impurity profiles have been provided for the proposed
and originator products.
Manufacturing Process
Satisfactory batch formulae have been provided for the manufacture of both strengths of
product, along with an appropriate account of the manufacturing process. The manufacturing
process has been validated and has shown satisfactory results.
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Finished Product Specification
The finished product specifications proposed for both strengths are acceptable. Test methods
have been described and have been adequately validated. Batch data have been provided and
comply with the release specification. Certificates of Analysis have been provided for all
working standards used.
Stability of the product
Stability studies were performed in accordance with current guidelines on batches of all
strengths of finished product packed in the packaging proposed for marketing. The data from
these studies support a shelf-life of 24 months, with the storage conditions ‘Do not store
above 25°C’.
Suitable post approval stability commitments have been provided to follow-up the batches
from the current studies.
Bioequivalence/bioavailability
Satisfactory Certificates of Analysis have been provided for the test and reference batches
used in the bioequivalence study.
II.4 Discussion on chemical, pharmaceutical and biological aspects
There are no objections to the approval of these applications from a pharmaceutical
viewpoint.
III. NON-CLINICAL ASPECTS
III.1 Introduction
As the pharmacodynamic, pharmacokinetic and toxicological properties of amoxicillin
trihydrate and potassium clavulanate are well-known, no further studies are required and
none have been provided.
The applicant’s non-clinical overview is satisfactory, providing an appropriate review of the
products’ pharmacology and toxicology.
A suitable justification has been provided for non-submission of an environmental risk
assessment. As these products are intended for generic substitution with products that are
already marketed, no increase in environmental burden is anticipated.
III.2 Pharmacology
Not applicable for this product type. Refer to section ‘III.1; Introduction’ detailed above.
III.3 Pharmacokinetics
Not applicable for this product type. Refer to section ‘III.1; Introduction’ detailed above.
III.4 Toxicology
Not applicable for this product type. Refer to section ‘III.1; Introduction’ detailed above.
III.6 Discussion on the non-clinical aspects
There are no objections to the approval of these applications from a non-clinical viewpoint.
IV CLINICAL ASPECTS
IV.1. Introduction
The clinical pharmacology of amoxicillin trihydrate and potassium clavulanate is well-
known. With the exception of data from the bioequivalence studies detailed below, no new
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pharmacodynamics or pharmacokinetic data are provided or are required for these
applications.
IV.2. Pharmacokinetics
In support of these applications, the Marketing Authorisation Holder has submitted the
following bioequivalence studies:
An open-label, randomised, two-period, two-treatment, two-sequence, single-dose,
crossover study to compare the pharmacokinetics of the test product Co-amoxiclav
500mg/125mg Film-coated Tablets versus the reference product Augmentin 625mg
Tablets (Beecham Group plc, UK) in healthy male volunteers under fasted conditions.
Volunteers were dosed with either treatment. Blood samples were taken for the measurement
of pharmacokinetic parameters at pre- and up to 12 hours post dose. The two treatment arms
were separated by a 7-day washout period.
The results are presented below: Amoxicillin (based on geometric means)
Parameter Test (T) Reference (R) % Ratio T/R 90% CI
Cmax (ng/ml) 7734.46 7269.43 106.39 98.06-115.44
AUC0-t 24651.87 23510.96 104.85 97.54-112.70
AUC0-inf 25152.51 24019.26 104.71 97.61-112.34
Clavulanic Acid (based on geometric means)
Parameter Test (T) Reference (R) % Ratio T/R 90% CI
Cmax (ng/ml) 2744.60 2726.76 100.65 88.36-114.65
AUC0-t 6266.60 6315.38 99.22 88.12-111.72
AUC0-inf 6490.39 6545.58 99.15 88.37-111.25
The test and reference products are within conventional 90% confidence intervals of 80-
125% for amoxicillin and clavulanic acid. In conclusion, bioequivalence has been shown
between the test and reference products.
An open-label, randomised, two-period, two-treatment, two-sequence, single-dose,
crossover study to compare the pharmacokinetics of the test product Co-amoxiclav
250mg/125mg Film-coated Tablets versus the reference product Augmentin 375mg
Tablets (Beecham Group plc, UK) in healthy male volunteers under fasted conditions.
Volunteers were dosed with either treatment. Blood samples were taken for the measurement
of pharmacokinetic parameters at pre- and up to 12 hours post dose. The two treatment arms
were separated by a 7-day washout period.
The results are presented below: Amoxicillin (based on geometric means)
Parameter Test Reference Ratio T/R % 90% CI
Cmax (ng/ml) 3939.22 4231.30 93.10 88.04-98.44
AUC0-t 12576.86 13214.18 95.18 90.77-99.80
Clavulanic Acid (based on geometric means)
Parameter Test Reference Ratio T/R % 90% CI
Cmax (ng/ml) 2462.74 2637.35 93.38 84.32-103.42
AUC0-t 5864.74 6354.97 92.29 83.62-101.85
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The test and reference products are within conventional 90% confidence intervals of
80-125% for amoxicillin and clavulanic acid. In conclusion, bioequivalence has been shown
between the test and reference products.
Efficacy
No new data on the efficacy of either active substance are submitted and none are required
for these types of applications.
Safety
No new or unexpected safety issues were raised by the bioequivalence data.
SmPC, PIL, Labelling
The SmPCs, PIL and labelling are medically acceptable. The SmPCs are consistent with
those for the originator products.
Conclusion
The grant of Marketing Authorisations is recommended.
IV.3 Pharmacodynamics
No new pharmacodynamic data were submitted and none were required for applications of
this type.
IV.4 Clinical efficacy
No new efficacy data were submitted, and none were required for applications of this type.
IV.5 Clinical safety
No new safety data were submitted and none are required.
IV.6 Risk Management Plan (RMP) and Pharmacovigilance System
The Pharmacovigilance System, as described by the applicant, fulfils the requirements and
provides adequate evidence that the applicant has the services of a qualified person
responsible for pharmacovigilance, and has the necessary means for the notification of any
adverse reaction suspected of occurring either in the Community or in a third country.
A suitable justification has been provided for not submitting a risk management plan for
these products.
IV.7 Discussion on the clinical aspects
The grant of marketing authorisations is recommended for these applications from a clinical
viewpoint.
V User consultation
The package leaflet has been evaluated via a user consultation study in accordance with the
requirements of Articles 59(3) and 61(1) of Directive 2001/83/EC. The language used for the
purpose of user testing the PIL was English.
The results show that the package leaflet meets the criteria for readability as set out in the
guideline on the readability of the label and package leaflet of medicinal products for human
use.
VI OVERALL CONCLUSION AND BENEFIT-RISK ASSESSMENT
QUALITY
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The important quality characteristics of Co-amoxiclav 250mg/125mg and 500mg/125mg
Film-coated Tablets are well-defined and controlled. The specifications and batch analytical
results indicate consistency from batch to batch. There are no outstanding quality issues that
would have a negative impact on the benefit-risk balance.
NON-CLINICAL
No new non-clinical data were submitted and none are required for applications of this type.
EFFICACY
Bioequivalence has been demonstrated between the applicant’s Co-amoxiclav 250mg/125mg
and 500mg/125mg Film-coated Tablets and their respective originator products.
No new or unexpected safety concerns arise from these applications.
The SmPCs, PIL and labelling are satisfactory and consistent with those for the originator
products.
RISK-BENEFIT ASSESSMENT
The quality of the products is acceptable, and no new preclinical or clinical safety concerns
have been identified. The bioequivalence study supports the claim that the applicant’s
products and the originator products are interchangeable. Extensive clinical experience with
amoxicillin and clavulanic acid is considered to have demonstrated the therapeutic value of
the compound. The benefit-risk is, therefore, considered to be positive.
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Summary of Product Characteristics (SmPC), Patient Information Leaflet (PIL) and
Labels
In accordance with Directive 2010/84/EU the Summaries of Product Characteristics (SmPCs)
and Patient Information Leaflets (PILs) for products granted Marketing Authorisations at a
national level are available on the MHRA website.
The approved labelling for these medicines is presented below:
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Annex 1
Table of content of the PAR update for MRP and DCP
Steps taken after the initial procedure with an influence on the Public Assessment Report
(Type II variations, PSURs, commitments)
Scope Procedur
e number
Product
informati
on
affected
Date of
start of the
procedure
Date of end
of
procedure
Approval/
non
approval
Assessme
nt report
attached
Y/N
(version)
To update
sections 4.2,
4.4, 4.8 and
5.1-5.2 of the
SPC as per
repeat use
commitment
Consequently
impacting the
PIL.
UK/H/324
4/001-
002/II/026
SmPC and
PIL
30/05/2018 21/12/2018 Approval Y
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Annex 1.1
Our Reference: PL 25298/0007 Application 0041 PL 25298/0008 Application 0036
Product Co-amoxiclav 250 mg/125 mg film-coated Tablets Co-
amoxiclav 500 mg/125 mg film-coated Tablets
Marketing Authorisation Holder: BROWN & BURK UK LIMITED
Active Ingredient(s): AMOXICILLIN TRIHYDRATE ,POTASSIUM
CLAVULANATE.
Type of Procedure: Mutual Recognition
Submission Type: Variation
Submission Category: Type II
Submission Complexity: Standard
EU Procedure Number: UK/H/3244/001-002/II/026
Reason:
To update sections 4.2, 4.4, 4.8 and 5.1-5.2 of the SmPC as per repeat use commitment.
Consequently, impacting the PIL.
Supporting Evidence:
These variation applications are submitted to update the product information as agreed during
the repeat use procedure for Co-amoxiclav 250 mg/125 mg and 500 mg/125 mg film-coated
Tablets.
Evaluation
The updated SmPC sections are satisfactory. The updated PIL is satisfactory. The updated
SmPC fragments and PIL have been incorporated into the Marketing Authorisation.
In accordance with Directive 2010/84/EU the Summaries of Product Characteristics (SmPCs)
and Patient Information Leaflets (PILs) for products granted Marketing Authorisations at a
national level are available on the MHRA website.
Decision – Approved on 21/12/2018