Fulsed

As intravenous sedative cover before and during minor medical, dental and surgical procedures such as gastroscopy, endoscopy, cystoscopy, bronchoscopy and cardiac catheterisation.

As an alternative intravenous agent for the induction of anaesthesia in high risk and elderly patients, especially where cardiovascular stability is of particular importance. Induction is more reliable when heavy opiate premedication has been administered or when Fulsed is given with a narcotic analgesic such as fentanyl.

As a sedative in intensive care units.

Posology

Intravenous sedation: One or more intravenous administrations over a single operating session. Severe cardio respiratory events have been reported and are most likely to occur when injection is given too rapidly or when too high dose is used.

When initiating an infusion with Fulsed in haemodynamically compromised patients, the usual loading dose should be titrated in small increments and the patient monitored for haemodynamic instability, e.g., hypotension. These patients are also vulnerable to the respiratory depressant effects of Fulsed and require careful monitoring of respiratory rate and oxygen saturation.

Adults: An assessment should be made of the degree of sedation necessary for the planned procedure.

The dose should be titrated against the response of the patient. The desired titration end point will depend upon the procedure. Full sedation will be evident by drowsiness, slurred speech but response to commands will be maintained.

As a guide, it is recommended that 2ml of Fulsed 1mg/1ml solution (equivalent to 2mg Fulsed) be administered intravenously over 30 seconds. If after 2 minutes, sedation is not adequate, incremental doses of 0.5ml to 1ml of Fulsed 1mg/1ml solution (0.5 to 1mg Fulsed) should be given.

Usual dose range 2.5mg - 7.5mg total dose (equivalent to around 0.07mg/kg body weight).

Dosages greater than 5.0mg are not usually necessary.

Older people: OLDER PATIENTS ARE MORE SENSITIVE TO THE EFFECTS OF BENZODIAZEPINES. IN THESE PATIENTS DOSES GREATER THAN 3.5MG ARE NOT USUALLY NECESSARY AND LOW DOSES AS LITTLE AS 1MG - 2MG (1.0 -2ML) MAY BE ADEQUATE. THE INITIAL DOSE SHOULD NOT EXCEED 1 -1.5MG (1 - 1.5ML).

Paediatric population:

Children over 6 months of age

In intubated and ventilated paediatric patients, a loading dose of 0.05 to 0.2 mg/kg i.v. should be administered slowly over at least 2 to 3 minutes to establish the desired clinical effect. Fulsed should not be administered as a rapid intravenous dose. The loading dose is followed by a continuous i.v. infusion at 0.06 to 0.12 mg/kg/h (1 to 2 µg/kg/min). The rate of infusion can be increased or decreased (generally by 25% of the initial or subsequent infusion rate) as required, or supplemental i.v. doses of Fulsed can be administered to increase or maintain the desired effect.

Neonates and children up to 6 months of age

Fulsed should be given as a continuous i.v. infusion, starting at 0.03 mg/kg/h (0.5 µg/kg/min) in neonates with a gestational age <32 weeks or 0.06 mg/kg/h (1 µg/kg/min) in neonates with a gestational age >32 weeks and children up to 6 months.

Intravenous loading doses is not recommended in premature infants, neonates and children up to 6 months, rather the infusion may be run more rapidly for the first several hours to establish therapeutic plasma levels. The rate of infusion should be carefully and frequently reassessed, particularly after the first 24 hours so as to administer the lowest possible effective dose and reduce the potential for drug accumulation.

Careful monitoring of respiratory rate and oxygen saturation is required.

In premature infants, neonates and children less than 15 kg of body weight, Fulsed solutions with concentrations higher than 1 mg/ml are not recommended. Higher concentrations should be diluted to 1 mg/ml.

Method of Administration: For the administration of Fulsed Injection, the patient should be placed in a supine position and remain there throughout the procedure. Resuscitation facilities should always be available and a second person fully trained in the use of such equipment should always be present. It is recommended that patients should remain under medical supervision until at least 1 hour has elapsed from the time of injection. They should always be accompanied home by a responsible adult.

Patients who have received Fulsed Injection alone for IV sedation prior to minor procedures should be warned not to drive or operate machinery for 12 hours. Where Fulsed is used concurrently with other central nervous system depressants (e.g. potent analgesics) recovery may be prolonged. Patients should therefore be assessed carefully before being allowed to go home or resume normal activities.

Combination therapy

Intravenous bolus sedation: where analgesia is provided by a narcotic analgesic the latter should be administered first, the dose of Fulsed should be carefully titrated and low doses 1 - 2mg (1.0- 2.0ml) may be adequate.

Use of this drug in patients with known hypersensitivity to benzodiazepines or to any excipient of the product

Use of this drug for conscious sedation in patients with severe respiratory failure, acute respiratory depression or unstable myasthenia gravis

Fulsed should be administered only by experienced physicians in a setting fully equipped for the monitoring and support of respiratory and cardiovascular function and by persons specifically trained in the recognition and management of expected adverse events including respiratory and cardiac resuscitation.

Severe cardiorespiratory adverse events have been reported. These have included respiratory depression, apnoea, respiratory arrest and/or cardiac arrest. Such life-threatening incidents are more likely to occur when the injection is given too rapidly or when a high dosage is administered.

Special caution is required for the indication of conscious sedation in patients with impaired respiratory function.

Paediatric patients less than 6 months:

In this population, Fulsed is indicated for sedation in ICU only. Paediatric patients less than 6 months of age are particularly vulnerable to airway obstruction and hypoventilation, therefore titration with small increments to clinical effect and careful respiratory rate and oxygen saturation monitoring are essential (see also section 'Preterm infants' below).

When Fulsed is used for premedication, adequate observation of the patient after administration is mandatory as inter-individual sensitivity varies and symptoms of overdose may occur.

Special caution should be exercised when administering Fulsed to high-risk patients:

− adults over 60 years of age

− chronically ill or debilitated patients, e.g.

− patients with chronic respiratory insufficiency

− patients with chronic renal failure, impaired hepatic function or with impaired cardiac function

− paediatric patients especially those with cardiovascular instability.

These high-risk patients require lower dosages and should be continuously monitored for early signs of alterations of vital functions.

As with any substance with CNS depressant and/or muscle-relaxant properties, particular care should be taken when administering Fulsed to a patient with myasthenia gravis.

Tolerance

Some loss of efficacy has been reported when Fulsed was used as long-term sedation in intensive care units (ICU).

Dependence

When Fulsed is used in long-term sedation in ICU, it should be borne in mind that physical dependence on Fulsed may develop. The risk of dependence increases with dose and duration of treatment it is also greater in patients with a medical history of alcohol and/or drug abuse.

Withdrawal symptoms

During prolonged treatment with Fulsed in ICU, physical dependence may develop. Therefore, abrupt termination of the treatment will be accompanied by withdrawal symptoms. The following symptoms may occur: headaches, muscle pain, anxiety, tension, restlessness, confusion, irritability, rebound insomnia, mood changes, hallucinations and convulsions. Since the risk of withdrawal symptoms is greater after abrupt discontinuation of treatment, it is recommended to decrease doses gradually.

Amnesia

Fulsed causes anterograde amnesia (frequently this effect is very desirable in situations such as before and during surgical and diagnostic procedures), the duration of which is directly related to the administered dose. Prolonged amnesia can present problems in outpatients, who are scheduled for discharge following intervention. After receiving Fulsed parenterally, patients should be discharged from hospital or consulting room only if accompanied by an attendant.

Paradoxical reactions

Paradoxical reactions such as agitation, involuntary movements (including tonic/clonic convulsions and muscle tremor), hyperactivity, hostility, rage reaction, aggressiveness, paroxysmal excitement and assault, have been reported to occur with Fulsed. These reactions may occur with high doses and/or when the injection is given rapidly. The highest incidence to such reactions has been reported among children and the elderly.

Altered elimination of Fulsed

Fulsed elimination may be altered in patients receiving compounds that inhibit or induce CYP3A4 and the dose of Fulsed may need to be adjusted accordingly

Fulsed elimination may also be delayed in patients with liver dysfunction, low cardiac output and in neonates

Preterm infants and neonates

Due to an increased risk of apnoea, extreme caution is advised when sedating pre-term and former pre-term non intubated patients. Careful monitoring of respiratory rate and oxygen saturation is required.

Rapid injection should be avoided in the neonatal population.

Neonates have reduced and/or immature organ function and are also vulnerable to profound and/or prolonged respiratory effects of Fulsed.

Adverse haemodynamic events have been reported in paediatric patients with cardiovascular instability; rapid intravenous administration should be avoided in this population.

Concomitant use of alcohol / CNS depressants

The concomitant use of Fulsed with alcohol or/and CNS depressants should be avoided. Such concomitant use has the potential to increase the clinical effects of Fulsed possibly including severe sedation or clinically relevant respiratory depression.

Medical history of alcohol or drug abuse

Fulsed as other benzodiazepines should be avoided in patients with a medical history of alcohol or drug abuse.

Discharging criteria

After receiving Fulsed, patients should be discharged from hospital or consulting room only when recommended by treating physician and if accompanied by an attendant. It is recommended that the patient is accompanied when returning home after discharge.

This medicinal product contains less than 1 mmol sodium (23 mg) per ampoule, i.e. essentially 'sodium- free'

Sedation, amnesia, impaired attention and impaired muscular function may adversely affect the ability to drive or use machines.

Prior to receiving Fulsed, the patient should be warned not to drive a vehicle or operate a machine until completely recovered. The physician should decide when these activities may be resumed. It is recommended that the patient is accompanied when returning home after discharge.

Where Fulsed is used concurrently with other central nervous system depressants (e.g. potent analgesics) recovery may be prolonged. Patients should therefore be assessed carefully before being allowed to go home or resume normal activities.

This medicine can impair cognitive function and can affect a patient's ability to drive safely. This class of medicine is in the list of drugs included in regulations under 5a of the Road Traffic Act 1988. When prescribing this medicine, patients should be told:

- The medicine is likely to affect your ability to drive

- Do not drive until you know how the medicine affects you

- It is an offence to drive while under the influence of this medicine

- However, you would not be committing an offence (called 'statutory defence') if:

o The medicine has been prescribed to treat a medical or dental problem and

o You have taken it according to the instructions given by the prescriber and in the information provided with the medicine and

o It was not affecting your ability to drive safely

The following undesirable effects have been reported ( frequency not known, cannot be estimated from the available data) to occur when Fulsed is injected:

Frequency categories are as follows:

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)

Not known (cannot be estimated from the available data)

* Such paradoxical drug reactions have been reported particularly among children and the elderly.

** Anterograde amnesia may still be present at the end of the procedure and in isolated cases prolonged amnesia has been reported.

*** The risk of falls and fractures is increased in those taking concomitant sedatives (including alcoholic beverages) and in the elderly.

Dependence: Use of Fulsed even in therapeutic doses may lead to the development of physical dependence. After prolonged IV administration, discontinuation, especially abrupt discontinuation of the product, may be accompanied by withdrawal symptoms including withdrawal convulsions. Cases of abuse have been reported.

Severe cardio-respiratory adverse events have occurred. Life-threatening incidents are more likely to occur in adults over 60 years of age and those with pre-existing respiratory insufficiency or impaired cardiac function, particularly when the injection is given too rapidly or when a high dosage is administered.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the MHRA Yellow Card Scheme.

Website: www.mhra.gov.uk/yellowcard

Symptoms

Like other benzodiazepines, Fulsed commonly causes drowsiness, ataxia, dysarthria and nystagmus. Overdose of Fulsed is seldom life-threatening if the drug is taken alone, but may lead to areflexia, apnoea, hypotension, cardiorespiratory depression and in rare cases to coma. Coma, if it occurs, usually lasts a few hours but it may be more protracted and cyclical, particularly in elderly patients. Benzodiazepine respiratory depressant effects are more serious in patients with respiratory disease.

Benzodiazepines increase the effects of other central nervous system depressants, including alcohol.

Treatment

Monitor the patient's vital signs and institute supportive measures as indicated by the patient's clinical state. In particular, patients may require symptomatic treatment for cardiorespiratory effects or central nervous system effects.

If CNS depression is severe consider the use of flumazenil, a benzodiazepine antagonist. This should only be administered under closely monitored conditions. It has a short half-life (about an hour), therefore patients administered flumazenil will require monitoring after its effects have worn off. Flumazenil is to be used with extreme caution in the presence of drugs that reduce seizure threshold (e.g. tricyclic antidepressants). Refer to the prescribing information for flumazenil, for further information on the correct use of this drug.

The correct information for using Flumazenil can also be obtained from the UK National Poison Information Service by calling on the following telephone number.

Tel: 0844-892-0111 (directs caller to relevant local centre.)

Pharmacotherapeutic group:

Hypnotics and sedatives (benzodiazepine derivatives), ATC code: N05CD08.

Fulsed is a derivative of the imidazobenzodiazepine group. The free base is a lipophilic substance with low solubility in water.

The basic nitrogen in position 2 of the imidazobenzodiazepine ring system enables the active ingredient of Fulsed to form water- soluble salts with acids. These produce a stable and well tolerated injection solution.

The pharmacological action of Fulsed is characterised by short duration because of rapid metabolic transformation. Fulsed has a sedative and sleep-inducing effect of pronounced intensity. It also exerts an anxiolytic, an anticonvulsant and a muscle-relaxant effect.

After i.m. or i.v. administration anterograde amnesia of short duration occurs (the patient does not remember events that occurred during the maximal activity of the compound).

Absorption after i.m. injection

Absorption of Fulsed from the muscle tissue is rapid and complete. Maximum plasma concentrations are reached within 30 minutes. The absolute bioavailability after i.m. injection is over 90%.

Distribution

When Fulsed is injected i.v., the plasma concentration-time curve shows one or two distinct phases of distribution. The volume of distribution at steady state is 0.7 - 1.2 l/kg. 96 - 98% of Fulsed is bound to plasma proteins. The major fraction of plasma protein binding is due to albumin. There is a slow and insignificant passage of Fulsed into the cerebrospinal fluid. In humans, Fulsed has been shown to cross the placenta slowly and to enter foetal circulation. Small quantities of Fulsed are found in human milk.

Metabolism

Fulsed is almost entirely eliminated by biotransformation. The fraction of the dose extracted by the liver has been estimated to be 30 - 60%. Fulsed is hydroxylated by the cytochrome P4503A4 isozyme and the major urinary and plasma metabolite is alpha-hydroxyFulsed. Plasma concentrations of alpha-hydroxyFulsed are 12% of those of the parent compound. Alpha-hydroxyFulsed is pharmacologically active, but contributes only minimally (about 10%) to the effects of intravenous Fulsed.

Elimination

In healthy volunteers, the elimination half-life of Fulsed is between 1.5 - 2.5 hours. Plasma clearance is in the range of 300 - 500ml/min. Fulsed is excreted mainly by renal route (60 - 80% of the injected dose) and recovered as glucuroconjugated alpha-hydroxyFulsed. Less than 1% of the dose is recovered in urine as unchanged drug. The elimination half-life of alpha-hydroxy-Fulsed is shorter than 1 hour. When Fulsed is given by i.v. infusion, its elimination kinetics do not differ from those following bolus injection.

Pharmacokinetics in special populations

Elderly

In adults over 60 years of age, the elimination half-life may be prolonged up to four times.

Children

The elimination half-life after i.v. administration is shorter in children 3 - 10 years old (1 - 1.5 hours) as compared with that in adults. The difference is consistent with an increased metabolic clearance in children.

Neonates

In neonates the elimination half-life is on average 6 - 12 hours, probably due to liver immaturity and the clearance is reduced.

Obese

The mean half-life is greater in obese than in non-obese patients (5.9 vs 2.3 hours). This is due to an increase of approximately 50% in the volume of distribution corrected for total body weight. The clearance is not significantly different in obese and non-obese patients.

Patients with hepatic impairment

The elimination half-life in cirrhotic patients may be longer and the clearance smaller as compared to those in healthy volunteers.

Patients with renal impairment

The elimination half-life in patients with chronic renal failure is similar to that in healthy volunteers.

Critically ill patients

The elimination half-life of Fulsed is prolonged up to six times in the critically ill.

Patients with cardiac insufficiency

The elimination half-life is longer in patients with congestive heart failure compared with that in healthy subjects.

There are no preclinical data of relevance to the prescriber which are additional to that already included in other sections of the SPC.

Fulsed Injection when mixed with 500ml infusion fluids containing dextrose 4% with sodium chloride 0.18%, dextrose 5% or sodium chloride 0.9% is chemically and physically stable for up to 24 hours at 25°C and up to 72 hours at 2 to 8°C. However, for pharmaceutical microbiological reasons, the product should be used immediately after dilution. When aseptically prepared, the diluted solution may be kept for not more than 24 hours if stored under refrigeration at a temperature between 2 - 8°C.

Admixture with Hartmann's solution is not recommended, as the potency of Fulsed decreases.

If only part used, discard the remaining solution.

No special requirements for disposal.

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.