Special Warning : אזהרת שימוש

Warnings
Long- term use of ibuprofen may increase the risk of heart attack or stroke.
Ibuprofen may cause a severe allergic reaction, especially in people allergic to
aspirin.
This product contains a nonsteroidal anti- inflammatory drug (NSAID), which may
cause stomach bleeding. The chance is higher if the patient is: over 60, has had
stomach ulcers or bleeding problems, takes a blood thinning (anticoagulant) or
steroid drug, takes other drugs containing an NSAID ( aspirin, ibuprofen , naproxen
or others), has 3 or more alcoholic drinks every day while using this product. Longer
duration of use and higher dosages are also risk factors.
Ibuprofen should be administered under close supervision to patients with a history
of upper gastrointestinal tract disease. If symptoms persist, worsen, or new
symptoms develop, the physician should be referred to.
Nurofen Plus tablets should be used with caution in those with hypotension and/ or
hypothyroidism. The tablets should be used with caution in patients with raised
intracranial pressure or head injury.

Use in Pregnancy
Administration of ibuprofen is not recommended during pregnancy.
The onset of labor may be delayed and duration of labor increased, therefore it is
recommended not to use ibuprofen during the last 3 months of pregnancy.
Based on animal studies and limited clinical experience there is no evidence to
suggest foetal abnormalities associated with the use of codeine. However, the
product should be avoided during pregnancy.

Use in Breastfeeding
Ibuprofen appears in breast milk in very low concentrations and is unlikely to affect
the breastfed infant adversely.
Codeine is excreted in breast milk.

Use in Pediatrics
This product is not to be used in children under 12 years of age.

Adverse Reactions
Adverse Reactions Attributed to Ibuprofen
Gastrointestinal
Epigastric pain, heartburn, diarrhea, abdominal distress, nausea and vomiting,
indigestion, constipation, abdominal cramps or pain, fullness of gastrointestinal tract, dyspepsia, gastrointestinal bleeding, peptic ulceration,.

Central Nervous System
Dizziness, severe headache, nervousness, convulsions, pain in the spinal column.

Dermatological
Rash (including maculopapular type), pruritus, photosensitivity, skin peeling.
Rarely exfoliative dermatitis and epidermal necrolysis have been reported with
ibuprofen.

Special Senses
Hearing disturbance.

Metabolic/Endocrine
Decreased appetite.

Cardiovascular
Edema, fluid retention (generally responds to drug discontinuation, see
Precautions).
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Hematological
Neutropenia,    agranulocytosis, aplastic   anemia,          hemolytic          anemia, thrombocytopenia, decreased hemoglobin and hematocrit.

Allergic
Fever.
Bronchospasm may be precipitated in patients with a history of aspirin-sensitive
asthma

Other Hypersensitivity Reactions:
Rarely hypersensitivity reactions with cutaneous eruptions, urticaria and pruritus,
as well as attacks of asthma, with or without drop in blood pressure, have been
observed. In single cases, severe hypersensitivity reactions, manifesting as facial
edema, swelling of the tongue, swelling of the larynx, dyspnea, tachycardia,
hypotension or severe shock have been reported. If these symptoms occur,
immediate medical attention is necessary.
In single cases, serious forms of skin reactions such as erythema multiforme can
occur.
In patients with existing auto-immune disorders (systemic lupus erythematosus,
mixed connective tissue disease) during treatment with ibuprofen, single cases of
symptoms of aseptic meningitis such as stiff neck, headache, nausea, vomiting, fever
or disorientation have been observed.
Other
Stiffness, sudden decrease in the amount of urine, black stools.
Renal papillary necrosis which can lead to renal failure.
Adverse Reactions Attributed to Codeine
Side effects to codeine include constipation, respiratory depression, cough
suppression, nausea and drowsiness

Precautions
Note
Patients sensitive to one of the non-steroidal anti-inflammatory agents (NSAIDs)
may be sensitive to any of the other NSAIDs also.
Blurred and/or diminished vision, scotomata, and changes in color vision have
been reported. If a patient develops such complaints while receiving ibuprofen, the
drug should be discontinued and the patient should have an ophthalmological
examination which includes central visual fields and color vision testing.
As with other NSAIDs, patients should be cautioned about engaging in activities
requiring mental alertness and motor coordination, such as driving a car.
Physicians should be consulted if patients taking ibuprofen exhibit signs or
symptoms of gastrointestinal ulceration or bleeding, blurred vision or other eye
symptoms, skin rash, weight gain, or edema.
Fluid retention and edema have been reported in association with ibuprofen.
Therefore, the drug should be used with caution in patients with a history of cardiac
decompensation or hypertension.
Since ibuprofen is eliminated primarily by the kidneys, patients with significantly
impaired renal function should be closely monitored, and a reduction in dosage
should be anticipated to avoid drug accumulation.
Ibuprofen should be used with caution in individuals with intrinsic coagulation
defects, and those on anticoagulant therapy.
Caution should be exercised when this product is administered to asthma sufferers
since bronchospasm may be precipitated in patients suffering from, or with a
previous history of bronchial asthma or allergic disease.
The elderly are at increased risk of the consequence of adverse reactions.

NUROFEN PLUS Tab   25. 12. 2005, RH                                 Page 3 of 6

Undesirable effects may be minimised by using the minimum effective dose for the
shortest possible duration.
Monitoring of blood urea nitrogen (BUN), serum creatinine concentrations and/or
serum potassium concentrations may be required at periodic intervals during therapy,
especially in patients with documented hepatic or renal function impairment.
The same monitoring may also be required in patients known or suspected to be at
risk for renal function impairment, patients taking diuretics concurrently, and in
patients in whom signs of possible renal toxicity occur, such as substantial increases in blood pressure, fluid retention, or rapid weight gain.
In order to avoid exacerbation of disease or adrenal insufficiency, patients who
have been on prolonged corticosteroid therapy should have their therapy reduced
slowly, rather than discontinued abruptly, when ibuprofen is added to the treatment
regimen.
As with other non-steroidal anti-inflammatory agents, borderline elevations of one
or more liver tests may occur in up to 15% of patients. These abnormalities may
progress, remain essentially unchanged, or be transient with continued therapy.
Because serious gastrointestinal tract ulcerations and bleeding can occur without
warning symptoms, physicians should follow chronically treated patients for the signs
and symptoms of ulcerations and bleeding and should inform them (in case of
children, the child’s parent/guardian) of importance of this follow-up.
Patients with symptoms and/or signs suggesting liver dysfunction, or in whom an
abnormal liver test has occurred, should be evaluated for evidence of the
development of more severe hepatic reactions while on therapy with ibuprofen.
Severe hepatic reactions, including jaundice and cases of fatal hepatitis, have been
reported with ibuprofen as with other non-steroidal anti-inflammatory agents.
Although such reactions are rare, if abnormal liver tests persist or worsen, or clinical signs and symptoms consistent with liver disease develop, or systemic
manifestations occur (e.g., eosinophilia, rash, etc.), ibuprofen should be
discontinued.
In cross-study comparisons with doses ranging from 1200-3200 mg daily for
several weeks, a slight dose-response decrease in hemoglobin/hematocrit was
noted.
Aseptic meningitis with fever and coma has been observed on rare occasions in
patients on ibuprofen therapy. Although it is probably more likely to occur in patients with systemic lupus erythematosus and related connective tissue diseases, it has
been reported in patients who do not have an underlying chronic disease. If signs or
symptoms of meningitis develop in a patient on ibuprofen, the possibility of its being related to ibuprofen should be considered.

There is some evidence that drugs which inhibit cyclo-oxygenase/ prostaglandin
synthesis may cause impairment of female fertility by an effect on ovulation. This is
reversible on withdrawal of treatment.

Patients Who Require Surgery (Including Dental Surgery)
Caution is recommended in patients who require surgery. Most of the Nonsteroidal
anti-inflammatory agents inhibit platelet aggregation and may prolong bleeding time,
which may increase intra-and postoperative bleeding. Consideration should therefore
be given to discontinuing NSAIDs treatment for an appropriate length of time prior to
elective surgery, depending on the potency and duration of effect of the individual
agent on platelet aggregability.
In case of patients requiring dental surgery, nonsteroidal anti-inflammatory agents
may cause soreness, irritation, or ulceration of the oral mucosa. Most of the
nonsteroidal anti-inflammatory agents may rarely cause leukopenia and/or
thrombocytopenia, which may result in an increased incidence of microbial infection,
delayed healing, and gingival bleeding. If leukopenia or thrombocytopenia occurs,
dental work should be deferred until blood counts return to normal, and patients
should be instructed in proper oral hygiene.
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Effects on Driving