`Soma' Compound with Codeine is a combination product containing carisoprodol, a centrally-acting muscle relaxant, plus aspirin, an analgesic with antipyretic and anti-inflammatory properties and codeine phosphate, a centrally-acting narcotic analgesic. It is available as a two-layered, white and yellow, oval-shaped tablet for oral administration. Each tablet contains carisoprodol 200 mg, aspirin 325 mg, and codeine phosphate 16 mg. Chemically, carisoprodol is N-isopropyl-2-methyl-2-propyl-1,3-propanediol dicarbamate. Its empirical formula is C 12 H 24 N 2 O 4 , with a molecular weight of 260.33. The structural formula is:
Other ingredients: croscarmellose sodium, D&C Yellow #10, hydroxypropyl methylcellulose, magnesium stearate, microcrystalline cellulose, povidone, sodium metabisulfite, starch, stearic acid.
Carisoprodol: Carisoprodol is a centrally-acting muscle relaxant that does not directly relax tense skeletal muscles in man. The mode of action of carisoprodol in relieving acute muscle spasm of local origin has not been clearly identified, but may be related to its sedative properties. In animals, carisoprodol has been shown to produce muscle relaxation by blocking interneuronal activity and depressing transmission of polysynaptic neurons in the spinal cord and in the descending reticular formation of the brain. The onset of action is rapid and lasts four to six hours.
Carisoprodol is metabolized in the liver and is excreted by the kidneys. It is dialyzable by peritoneal and hemodialysis.
Aspirin: Aspirin is a non-narcotic analgesic with anti-inflammatory and antipyretic activity. Inhibition of prostaglandin biosynthesis appears to account for most of its anti-inflammatory and for at least part of its analgesic and antipyretic properties.
Aspirin is rapidly absorbed and almost totally hydrolyzed to salicylic acid following oral administration. Although aspirin has a half-life of only about 15 minutes, the apparent biologic half-life of salicylic acid in the therapeutic plasma concentration range is between 6 and 12 hours. Salicylic acid is eliminated by renal excretion and by biotransformation to inactive metabolites. Clearance of salicylic acid in the high-dose range is sensitive to urinary pH (see Drug Interactions ) and is reduced by renal dysfunction.
Codeine Phosphate: Codeine phosphate is a centrally-acting narcotic-analgesic. Its actions are qualitatively similar to morphine, but its potency is substantially less.
Clinical studies have shown that combining aspirin and codeine produces a significant additive effect in analgesic efficacy.
`Soma' Compound with Codeine is indicated as an adjunct to rest, physical therapy, and other measures for the relief of pain, muscle spasm, and limited mobility associated with acute, painful musculoskeletal conditions when the additional action of codeine is desired.
Acute intermittent porphyria; bleeding disorders; allergic or idiosyncratic reactions to carisoprodol, aspirin, codeine, or related compounds.
On very rare occasions, the first dose of carisoprodol has been followed by idiosyncratic reactions, with symptoms appearing within minutes or hours. These may include extreme weakness, transient quadriplegia, dizziness, ataxia, temporary loss of vision, diplopia, mydriasis, dysarthria, agitation, euphoria, confusion, and disorientation. Although symptoms usually subside over the course of the next several hours, discontinue `Soma' Compound with Codeine and initiate appropriate supportive and symptomatic therapy, which may include epinephrine and/or antihistamines. In severe cases, corticosteroids may be necessary. Severe reactions have been manifested by asthmatic episodes, fever, weakness, dizziness, angioneurotic edema, smarting eyes, hypotension, and anaphylactoid shock.
The effects of carisoprodol with agents such as alcohol, other CNS depressants, or psychotropic drugs may be additive. Appropriate caution should be exercised with patients who take one or more of these agents simultaneously with Soma Compound with Codeine.
Contains sodium metabisulfite, a sulfite that may cause allergic-type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people. The overall prevalence of sulfite sensitivity in the general population is unknown and probably low. Sulfite sensitivity is seen more frequently in asthmatic than in nonasthmatic people.
General: To avoid excessive accumulation of carisoprodol, aspirin, or their metabolites, use `Soma' Compound with Codeine with caution in patients with compromised liver or kidney function, or in elderly or debilitated patients (see ).
Use with caution in patients with history of gastritis or peptic ulcer, in patients on anticoagulant therapy, and in addiction-prone individuals.
Information for Patients: Caution patients that this drug may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks such as driving a motor vehicle or operating machinery.
Caution patients with a predisposition for gastrointestinal bleeding that concomitant use of aspirin and alcohol may have an additive effect in this regard.
Caution patients that dosage of medications used for gout, arthritis, or diabetes may have to be adjusted when aspirin is administered or discontinued (see Drug Interactions ).
Drug Interactions: Clinically important interactions may occur when certain drugs are administered concomitantly with aspirin or aspirin-containing drugs.
Carcinogenesis, Mutagenesis, Impairment of Fertility: No long-term studies have been done with `Soma' Compound with Codeine.
Pregnancy--Teratogenic Effects: Pregnancy Category C. Adequate animal reproduction studies have not been conducted with `Soma' Compound with Codeine. It is also not known whether `Soma' Compound with Codeine can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. `Soma' Compound with Codeine should be given to a pregnant woman only if clearly needed.
Studies in rodents have shown salicylates to be teratogenic when given in early gestation, and embryocidal when given in later gestation in doses considerably greater than usual therapeutic doses in humans. Studies in women who took aspirin during pregnancy have not demonstrated an increased incidence of congenital abnormalities in the offspring.
Labor and Delivery: Ingestion of aspirin near term or prior to delivery may prolong delivery or lead to bleeding in mother, fetus, or neonate.
Nursing Mothers: Carisoprodol is excreted in human milk in concentrations two-to-four times that in maternal plasma. Aspirin is excreted in human milk in moderate amounts and can produce a bleeding tendency in nursing infants. Because of the potential for serious adverse reactions in nursing infants, a decision should be made whether to discontinue nursing or the drug, taking into account the importance of the drug to the mother.
Pediatric Use: Safety and effectiveness in children below the age of twelve have not been established.
If severe reactions occur, discontinue `Soma' Compound with Codeine and initiate appropriate symptomatic and supportive therapy.
The following side effects which have occurred with the administration of the individual ingredients alone may also occur with the combination.
Carisoprodol: Central Nervous System --Drowsiness is the most frequent complaint and along with other CNS effects may require dosage reduction. Observed less frequently are dizziness, vertigo and ataxia. Tremor, agitation, irritability, headache, depressive reactions, syncope, and insomnia have been infrequent or rare.
Idiosyncratic --Idiosyncratic reactions are very rare. They are usually seen within the period of the first to fourth dose in patients having had no previous contact with the drug (see ).
Allergic --Skin rash, erythema multiforme, pruritus, eosinophilia, and fixed drug eruptions with cross-reaction to meprobamate have been reported. If allergic reactions occur, discontinue `Soma' Compound with Codeine and treat symptomatically. In evaluating possible allergic reactions, also consider allergy to excipients (information on excipients is available to physicians on request).
Cardiovascular --Tachycardia, postural hypotension, and facial flushing.
Gastrointestinal --Nausea, vomiting, epigastric distress and hiccup.
Hematologic --No serious blood dyscrasias have been attributed to carisoprodol alone. Leukopenia and pancytopenia have been reported, very rarely, in situations in which other drugs or viral infections may have been responsible.
Aspirin: The most common adverse reactions associated with the use of aspirin have been gastrointestinal, including nausea, vomiting, gastritis, occult bleeding, constipation and diarrhea. Gastric erosion, angioedema, asthma, rash, pruritus and urticaria have been reported less commonly. Tinnitus is a sign of high serum salicylate levels (see OVERDOSAGE ).
Aspirin Intolerance --Allergic type reactions in aspirin-sensitive individuals may involve the respiratory tract or the skin. Symptoms of the former range from rhinorrhea and shortness of breath to severe asthma, and the latter may consist of urticaria, edema, rash, or angioedema (giant hives). These may occur independently or in combination.
Codeine Phosphate: Nausea, vomiting, constipation, miosis, sedation, and dizziness have been reported.
Controlled Substance: Schedule C-III (see PRECAUTIONS ).
Abuse: In clinical use, abuse has been rare.
Dependence: In clinical use, dependence with `Soma' Compound with Codeine has been rare and there have been no reports of significant abstinence signs. Nevertheless, the following information on the individual ingredients should be kept in mind.
Carisoprodol --In dogs, no withdrawal symptoms occurred after abrupt cessation of carisoprodol from dosages as high as 1 gm/kg/day. In a study in man, abrupt cessation of 100 mg/kg/day (about five times the recommended daily adult dosage) was followed in some subjects by mild withdrawal symptoms such as abdominal cramps, insomnia, chills, headache, and nausea. Delirium and convulsions did not occur (see PRECAUTIONS ).
Codeine Phosphate-- Drug dependence of the morphine type may result.
Signs and Symptoms: Any of the following which have been reported with the individual ingredients may occur and may be modified to a varying degree by the effects of the other ingredients present in `Soma' Compound with Codeine.
Carisoprodol --Stupor, coma, shock, respiratory depression and, very rarely, death. Overdosage with carisoprodol in combination with alcohol, other CNS depressants, or psychotropic agents can have additive effects, even when one of the agents has been taken in the usually recommended dosage.
Aspirin --Headache, tinnitus, hearing difficulty, dim vision, dizziness, lassitude, hyperpnea, rapid breathing, thirst, nausea, vomiting, sweating and occasionally diarrhea are characteristic of mild to moderate salicylate poisoning. Salicylate poisoning should be considered in children with symptoms of vomiting, hyperpnea, and hyperthermia.
Hyperpnea is an early sign of salicylate poisoning, but dyspnea supervenes at plasma levels above 50 mg/dl. These respiratory changes eventually lead to serious acid-base disturbances. Metabolic acidosis is a constant finding in infants but occurs in older children only with severe poisoning; adults usually exhibit respiratory alkalosis initially and acidosis terminally.
Other symptoms of severe salicylate poisoning include hyperthermia, dehydration, delirium, and mental disturbances. Skin eruptions, GI hemorrhage, or pulmonary edema are less common. Early CNS stimulation is replaced by increasing depression, stupor, and coma. Death is usually due to respiratory failure or cardiovascular collapse.
Codeine Phosphate-- pinpoint pupils, CNS depression, coma, respiratory depression, and shock.
Treatment: General --Provide symptomatic and supportive treatment, as indicated. Any drug remaining in the stomach should be removed using appropriate procedures and caution to protect the airway and prevent aspiration, especially in the stuporous or comatose patient. Incomplete gastric emptying with delayed absorption of carisoprodol has been reported as a cause for relapse. Should respiration or blood pressure become compromised, respiratory assistance, central nervous system stimulants, and pressor agents should be administered cautiously, as indicated.
Carisoprodol --The following have been used successfully in overdosage with the related drug meprobamate: diuretics, osmotic (mannitol) diuresis, peritoneal dialysis, and hemodialysis (see ). Careful monitoring of urinary output is necessary and caution should be taken to avoid overhydration. Carisoprodol can be measured in biological fluid by gas chromatography (Douglas, J. F., et al: J Pharm Sci 58: 145, 1969).
Aspirin --Since there are no specific antidotes for salicylate poisoning, the aim of treatment is to enhance elimination of salicylate and prevent or reduce further absorption; to correct any fluid, electrolyte or metabolic imbalance; and to provide general and cardiorespiratory support. If acidosis is present, intravenous sodium bicarbonate must be given, along with adequate hydration, until salicylate levels decrease to within the therapeutic range. To enhance elimination, forced diuresis and alkalinization of the urine may be beneficial. The need for hemoperfusion or hemodialysis is rare and should be used only when other measures have failed.
Codeine Phosphate-- Narcotic antagonists, such as nalorphine and levallorphan, may be indicated.
Usual Adult Dosage: 1 or 2 tablets, four times daily.
Not recommended for use in children under age twelve.
`Soma' Compound with Codeine Tablets (carisoprodol, USP 200 mg, aspirin 325 mg, and codeine phosphate, USP 16 mg) are oval, convex, two-layered and inscribed on the white layer with SOMA CC and on the yellow layer with WALLACE 2403. The tablets are available in bottles of 100 (NDC 0037-2403-01).
Storage: Store at controlled room temperature 15°-30°C (59°-86°F). Protect from moisture.
Dispense in a tight container.
Division of CARTER-WALLACE, INC.
Cranbury, New Jersey 08512
IN-095E2-12 Rev. 9/93
Patent No. 4534974