Lactulose 10 g/15 ml oral solution sachets

One sachet (15 ml) contains 10 g Lactulose (as lactulose liquid).

Oral solution

Clear colourless to pale brownish yellow, viscous solution

Symptomatic treatment of Constipation

Lactulose may be administered diluted or undiluted. The dose should be titrated according to the clinical response. Lactulose may be given as a single daily dose or in two to three divided doses.

A single dose of lactulose should be swallowed in one and should not be kept in the mouth for an extended period of time.

The posology should be adjusted according to the individual needs of the patient. The starting dose can be adjusted after adequate treatment effect individually (maintenance dose). Several days (2-3 days) of treatment may be needed in some patients before adequate treatment effect occurs. In case of single daily dose, this should be taken at the same time of the day, e.g. during breakfast. During the therapy with laxatives it is recommended to drink sufficient amounts of fluids (1.5-2 l/day, equal to 6-8 glasses).

For a precise dosing for babies, toddlers and children up to 6 years, it should be noted that not all included dose recommendations can be carried out with Lactulose and that other authorised products are available.

If diarrhoea occurs, the dosing regimen should be reduced.
In elderly patients and patients with renal or hepatic insufficiency no special dosage recommendations exist.

Duration of treatment
The duration of treatment has to be adopted according to the symptoms.

4.3. Contraindications

• Hypersensitivity to any of the components of the product.
• Use in patients with galactosaemia.
• Acute inflammatory bowel disease (ulcerative colitis, Crohn's disease),gastrointestinal obstruction or subocclusive syndromes, digestive perforation or risk of digestive perforation, painful abdominal syndromes of undetermined cause.

4.4. Special warnings and precautions for use

• In case of insufficient therapeutic effect after several days consultation of a physician is advised.
• From the route of synthesis Lactulose may contain small amounts of sugars
• (Not more than 67 mg/ml lactose, 100 mg/ml galactose, 67 mg/ml epilactose, 27 mg/ml tagatose and 7 mg/ml fructose).
• Patients with rare hereditary problems of galactose or fructose intolerance, lactase deficiency or glucose-galactose mal-absorption should not take this medicine.
• Lactulose should be administered with care to patients who are intolerant to lactose.
• The dose normally used should not pose a problem for diabetics.
• 15 ml of lactulose contain 42.7 KJ (10.2 kcals) = 0.21 BU.
• For patients with gastro-cardiac syndrome (Roemheld syndrome) lactulose should only be taken after consultation of a physician. If symptoms like meteorism or bloating occur in such patients after lactulose intake, the dose should be reduced or the treatment should be discontinued.
• Chronic use of unadjusted doses and misuse can lead to diarrhoea and disturbance of the electrolyte balance.
• For elderly patients or patients that are in bad general condition and who take lactulose for a more than 6 months period, periodic control of electrolytes is indicated.
• During the therapy with laxatives it is recommended to drink sufficient amounts of fluids (1.5-2 l/day, equal to 6-8 glasses).
• Children up to 6 years:
• Use of laxatives in children should be exceptional and under medical supervision.
• Lactulose should be administrated with caution in infants and small children with autosomal recessive hereditary fructose intolerance.
• The defecation reflex may be altered during the treatment with lactulose.

4.5. Interaction with other medicinal products and other forms of interaction

• Lactulose may increase the loss of potassium induced by other drugs (e.g. thiazides, steroids and amphothericin B). Concomitant use of cardiac glycosides can increase the effect of the glycosides through potassium deficiency.
• With increasing dosage a decrease of pH-value in the colon is found. Therefore drugs which are released in the colon pH-dependently (e.g. 5-ASA) can be inactivated.

4.6. Pregnancy and lactation
Limited data on pregnant patients indicate no malformative nor foeto/neonatal toxicity. Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, parturition or postnatal development (see section 5.3).
The use of Lactulose may be considered during pregnancy if necessary.
Lactulose can be used during breastfeeding.

4.7. Effects on ability to drive and use machines
Lactulose has no or negligible influence on the ability to drive and use machines.

4.8. Undesirable effects

Very common	≥ 1/10
Common	≥1/100 to < 1/10
Uncommon	≥1/1,000 to <1/100
Rare	≥1/10,000 to < 1/1,000
Very rare	< 1/10,000

Flatulence may occur during the first few days of treatment. As a rule it disappears after a couple of days. When dosages higher than instructed are used, abdominal pain and diarrhoea may occur. In such a case the dosage should be decreased.

Gastrointestinal disorders
Very common (≥ 1/10): Flatulence, abdominal pain,
Common (≥ 1/100 < 1/10): nausea and vomiting; if dosed too high, diarrhoea.

Investigations
Electrolyte imbalance due to diarrhoea.

4.9. Overdose
If the dose is too high, the following may occur:
Symptom: diarrhoea and abdominal pain.
Treatment: cessation of treatment or dose reduction. Extensive fluid loss by diarrhoea or vomiting may require correction of electrolyte disturbances.

5. Pharmacological properties

5.1. Pharmacodynamic properties

Pharmacotherapeutic group: Osmotically acting laxatives.
ATC code: A06A D11
Lactulose is a synthetic disaccharide formed from D-galactose and fructose. In the colon lactulose is metabolised by bacterial enzymes to short chained fatty acids mainly lactic and acetic acid as well as methane and hydrogen. This effect leads to a decrease of the pH-value and an increase of the osmotic pressure in the colon. This causes stimulation of peristalsis and an increase of the water content of the faeces.

5.2. Pharmacokinetic properties

Lactulose is practically not absorbed, because in man there is no corresponding disaccharidase available in the upper intestinal tract. Not being absorbed as such, it reaches the colon unchanged. There it is metabolised by the colonic bacterial flora. Metabolism is complete at doses up to 25-50 g or 40-75 ml; at higher dosages, a proportion may be excreted unchanged.

5.3. Preclinical safety data
Preclinical data based on studies of single and repeated dose toxicity reveal no special hazards for humans. A long-term animal study does not give reference to tumorigenic potential. Lactulose was not teratogenic in mice, rats and rabbits. After oral administration systemic toxicity is not to be expected due to the pharmacological and pharmacokinetic properties of lactulose.