Levosan

Indicated for the treatment of primary and secondary carnitine deficiency in adults and children over 12 years of age.

Indicated for the treatment of primary and secondary carnitine deficiency in children of under 12 years, infants and newborns.

Adults and children over 12 years of age

The tablets should be given in divided doses.

It is advisable to monitor therapy by measuring free and acyl carnitine levels in both plasma and urine.

The management of inborn errors of metabolism

The dosage required depends upon the specific inborn error of metabolism concerned and the severity of presentation at the time of treatment. However, the following can be considered as a general guide.

An oral dosage of up to 200mg/kg/day in divided doses (2 to 4) is recommended for chronic use in some disorders, with lower doses sufficing in other conditions. If clinical and biochemical symptoms do not improve, the dose may be increased on a short-term basis. Higher doses of up to 400mg/kg/day may be necessary in acute metabolic decompensation or the i.v. route may be required.

Haemodialysis - maintenance therapy

If significant clinical benefit has been gained by a first course of intravenous Levosan then maintenance therapy can be considered using 1 g per day of Levosan orally. On the day of the dialysis oral Levosan has to be administered at the end of the session.

Method of administration

For oral administration only.

For oral administration only. The Paediatric Solution can be drunk directly or diluted further in water or fruit juices.

Children under 12 years, infants and newborns:

It is advisable to monitor therapy by measuring free and acyl carnitine levels in both plasma and urine.

The management of inborn errors of metabolism

The dosage required depends upon the specific inborn error of metabolism concerned and the severity of presentation at the time of treatment. However, the following can be considered as a general guide.

An oral dosage of up to 200mg/kg/day in divided doses (2 to 4) is recommended for chronic use in some disorders, with lower doses sufficing in other conditions. If clinical and biochemical symptoms do not improve, the dose may be increased on a short-term basis. Higher doses of up to 400mg/kg/day may be necessary in acute metabolic decompensation or the i.v. route may be required.

Haemodialysis - maintenance therapy

If significant clinical benefit has been gained by a first course of intravenous Levosan then maintenance therapy can be considered using 1g per day of Levosan orally. On the day of the dialysis oral Levosan has to be administered at the end of the session.

Hypersensitivity to any of the constituents of the product.

There is limited experience of use in patients with primary and secondary systemic carnitine deficiency suffering from renal failure.

The chewable tablets contain sucrose. This must be considered when treating diabetics or patients who are following diets to reduce calorie intake. Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrose-isomaltase insufficiency should not take this medicine.

While improving glucose utilisation, the administration of Levosan to diabetic patients receiving either insulin or hypoglycaemic oral treatment may result in hypoglycaemia.

Plasma glucose levels in these subjects must be monitored regularly in order to adjust the hypoglycaemic treatment immediately, if required.

The 30% oral solution contains sucrose. This must be considered when treating diabetics or patients who are following diets to reduce calorie intake.

The safety and efficacy of oral Levosan has not been evaluated in patients with renal insufficiency. Chronic administration of high doses of oral Levosan in patients with severely compromised renal function or in end stage renal disease (ESRD) patients on dialysis may result in an accumulation of the potentially toxic metabolites, trimethylamine (TMA) and trimethylamine-N-oxide (TMAO), since these metabolites are usually excreted in the urine. This situation has not been observed following intravenous administration of Levosan.

Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take this medicine.

There have been very rare reports of International Normalised Ratio (INR) increased in patients treated concomitantly with Levosan and coumarinic drugs. ''Undesirable Effects'.

Adverse reactions from any source are listed in the table below by MedRA system organ class. Within each system organ class, the adverse drug reactions are ranked by frequency. Within each frequency grouping, adverse reactions are ranked in order of decreasing seriousness. In addition the corresponding frequency category for each adverse drug reaction is based on the following conventions: very common (>1/10); common (>1/100, <1/10); uncommon (>1/1,000, <1/100); rare (>1/10,000, <1/1,000); very rare (<1/10,000).

Decreasing the dosage often diminishes or eliminates drug related patient body odour or gastro-intestinal symptoms when present. Tolerance should be monitored very closely during the first week of administration and after any dosage increase.

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 Yellow Card Scheme at: www.mhra.gov.uk/yellowcard

Adverse reactions from any source are listed in the table below by MedRA system organ class. Within each system organ class, the adverse drug reactions are ranked by frequency. Within each frequency grouping, adverse reactions are ranked in order of decreasing seriousness. In addition the corresponding frequency category for each adverse drug reaction is based on the following conventions: very common (>1/10); common (>1/100, <1/10); uncommon (>1/1,000, <1/100); rare (>1/10,000, <1/1,000); very rare (<1/10,000).

* There have been very rare reports of International Normalised Ratio (INR) increased in patients treated concomitantly with Levosan and coumarinic drugs (acenocumarol and warfarin) -see Section 4.4 ''Interactions'.

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Decreasing the dosage often diminishes or eliminates drug related patient body odour or gastro-intestinal symptoms when present. Tolerance should be monitored very closely during the first week of administration and after any dosage increase.

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 internet at www.mhra.gov.uk/yellowcard alternatively you can call Freephone 0808 100 3352 available between 10am -2pm Monday-Friday) or fill in a paper form available from pharmacies.

There have been no reports of toxicity from levocarnitine overdosage. Overdosage should be treated with supportive care.

There have been no reports of toxicity from Levosan overdosage. Overdosage should be treated with supportive care.

Pharmacotherapeutic group: Amino acids and derivatives

ATC Code: A16AA01

Levocarnitine is present as a natural constituent in animal tissues, micro-organisms and plants. In man the physiological metabolic requirements are met both by the consumption of food containing carnitine and the endogenous synthesis in the liver and kidneys from lysine with methionine serving as the methyl donor. Only the L-isomer is biologically active, playing an essential role in lipid metabolism as well as in the metabolism of ketone bodies as branched chain-amino-acids. Levocarnitine as a factor is necessary in the transport of long-chain fatty acids into the mitochondria - facilitating the oxidation of fatty acids rather than their incorporation into triglycerides. By releasing CoA from its thioesters, through the action of CoA; carnitine acetyl transferase, levocarnitine also enhances the metabolic flux in the Kreb's cycle; with the same mechanism it stimulates the activity of pyruvate dehydrogenase and in skeletal muscle, the oxidation of branched-chain amino acids. Levocarnitine is thus involved, directly or indirectly in several pathways so that its availability should be an important factor controlling not only the oxidative utilisation of fatty acids and ketone bodies but also that of glucose and some amino acids.

ATC Code: A16AA01 (Amino acids and derivatives)

Levosan is present as a natural constituent in animal tissues, micro-organisms and plants. In man the physiological metabolic requirements are met both by the consumption of food containing carnitine and the endogenous synthesis in the liver and kidneys from lysine with methionine serving as the methyl donor. Only the L-isomer is biologically active, playing an essential role in lipid metabolism as well as in the metabolism of ketone bodies as branched chain-amino-acids. Levosan as a factor is necessary in the transport of long-chain fatty acids into the mitochondria - facilitating the oxidation of fatty acids rather than their incorporation into triglycerides. By releasing CoA from its thioesters, through the action of CoA; carnitine acetyl transferase, Levosan also enhances the metabolic flux in the Kreb's cycle; with the same mechanism it stimulates the activity of pyruvate dehydrogenase and in skeletal muscle, the oxidation of branched-chain amino acids. Levosan is thus involved, directly or indirectly in several pathways so that its availability should be an important factor controlling not only the oxidative utilisation of fatty acids and ketone bodies but also that of glucose and some amino acids.

The absorbed levocarnitine is transported to various organ systems via the blood. The presence of membrane-bound proteins in several tissues including red blood cells that bind carnitine, suggest that a transport system in the blood and a cellular system for the collective uptake is present in several tissues. Tissue and serum carnitine concentration depend on several metabolic processes, carnitine bio-synthesis and dietary contributions, transport into and out of tissues, degradation and excretion may all affect tissue carnitine concentrations.

Absorption

Levocarnitine is absorbed by the mucosal cells of the small intestine and enters the blood stream relatively slowly; the absorption is probably associated with an active transluminal mechanism.

The apparent systemic availability after oral administration is limited (<10%) and variable.

Distribution

Absorbed levocarnitine is transported to various organ systems via the blood; it is thought that a transport system in the blood and a cellular system for selective uptake is involved.

Biotransformation

Levocarnitine is metabolised to a very limited extent.

Elimination

Levocarnitine is excreted mainly in the urine and is variable. The excretion is directly proportional to the blood levels.

The absorbed Levosan is transported to various organ systems via the blood. The presence of membrane-bound proteins in several tissues including red blood cells that bind carnitine, suggest that a transport system in the blood and a cellular system for the collective uptake is present in several tissues. Tissue and serum carnitine concentration depend on several metabolic processes, carnitine bio-synthesis and dietary contributions, transport into and out of tissues, degradation and excretion may all affect tissue carnitine concentrations.

It has been demonstrated that pharmacokinetic parameters increase significantly with dosage. Apparent bioavailability in healthy volunteers is about 10-16%. The data suggests a relationship between maximal plasma concentration/dosage, dosage, plasma AUC, dosage/urinary accumulation. Maximum concentration is reached about four hours after ingestion.

Levocarnitine is a naturally occurring body substance in human beings, plants and animals. Levosan products are used to bring the level of levocarnitine in the body up to those found naturally. Appropriate pre-clinical studies have been undertaken and show no signs of toxicity at normal therapeutic levels.

Levosan is a naturally occurring body substance in human beings, plants and animals. Carnitor products are used to bring the level of Levosan in the body up to those found naturally. Appropriate pre-clinical studies have been undertaken and show no signs of toxicity at normal therapeutic doses.