Paracetamol Alter

Paracetamol Alter is indicated for the short-term treatment of moderate pain, especially following surgery and for the short-term treatment of fever, when administration by intravenous route is clinically justified by an urgent need to treat pain or hyperthermia and/or when other routes of administration are not possible.

Intravenous route.

The 100 ml vial is restricted to adults, adolescents and children weighing more than 33 kg.

The 50 ml vial is adapted to term newborn infants, infants, toddlers and children weighing less than 33 kg.

Posology:

Dosing based on patient weight (please see the dosing table here below)

* Pre-term newborn infants: No safety and efficacy data are available for pre-term newborn infants.

** Patients weighing less will require smaller volumes.

The minimum interval between each administration must be at least 4 hours. No more than 4 doses to be given in 24 hours.

The minimum interval between each administration in patients with severe renal insufficiency must be at least 6 hours.

*** Maximum daily dose: The maximum daily dose as presented in the table above is for patients that are not receiving other paracetamol containing products and should be adjusted accordingly taking such products into account.

Severe renal insufficiency:

It is recommended, when giving paracetamol to patients with severe renal impairment (creatinine clearance ≤ 30 mL/min), to increase the minimum interval between each administration to 6 hours.

In adults with hepatocellular insufficiency, chronic alcoholism, chronic malnutrition (low reserves of hepatic glutathione), dehydration:

The maximum daily dose must not exceed 3 g.

Method of administration:

The paracetamol solution is administered as a 15-minute intravenous infusion.

Patients weighing ≤ 10 kg:

- The glass vial of Paracetamol Alter should not be hung as an infusion due to the small volume of the medicinal product to be administered in this population

- The volume to be administered should be withdrawn from the vial and could be administered undiluted or diluted (from one to nine volumes diluent) in a 0.9% sodium chloride solution or 5% glucose solution and administered in 15-minute.

Use the diluted solution within the hour following its preparation (infusion time included).

- A 5 or 10 ml syringe should be used to measure the dose as appropriate for the weight of the child and the desired volume. However, this should never exceed 7.5ml per dose

- The user should be referred to the product information for dosing guidelines.

Text for the 50ml and 100ml vials:

To remove solution, use a 0.8 mm needle (21 gauge needle) and vertically perforate the stopper at the spot specifically indicated.

As for all solutions for infusion presented in glass vials, it should be remembered that close monitoring is needed notably at the end of the infusion, regardless of administration route. This monitoring at the end of the perfusion applies particularly for central route infusion, in order to avoid air embolism.

Text for the 50ml vial:

Paracetamol Alter of 50ml vial can also be diluted in a 0.9% sodium chloride solution or 5% glucose solution (from one to nine volumes diluent). In this case, use the diluted solution within the hour following its preparation (infusion time included).

Paracetamol Alter is contraindicated:

â–ª in patients with hypersensitivity to paracetamol or to propacetamol hydrochloride (prodrug of paracetamol) or to one of the excipients.

â–ª in cases of severe hepatocellular insufficiency.

Warnings

It is recommended to use a suitable analgesic oral treatment as soon as this administration route is possible.

In order to avoid the risk of overdose, check that other medicines administered do not contain either paracetamol or propacetamol.

Doses higher than the recommended entails risk for very serious liver damage. Clinical symptoms and signs of liver damage (including fulminant hepatitis, hepatic failure, cholestatic hepatitis, cytolytic hepatitis) are usually first seen after two days of drug administration with a peak seen usually after 4 - 6 days. Treatment with antidote should be given as soon as possible.

This medicinal product contains less than 1 mmol sodium (23mg) per 100ml of Paracetamol Alter, i.e. essentially "sodium free".

Text for the 50ml and 100ml vials:

As for all solutions for infusion presented in glass vials, a close monitoring is needed notably at the end of the infusion.

Precautions for use

Paracetamol should be used with caution in cases of:

â–ª hepatocellular insufficiency,

▪ severe renal insufficiency (creatinine clearance ≤ 30 mL/min) ,

â–ª chronic alcoholism,

â–ª chronic malnutrition (low reserves of hepatic gluthatione),

â–ª dehydration.

Not relevant.

As all paracetamol products, adverse drug reactions are rare (>1/10000, <1/1000) or very rare (<1/10000), they are described below:

Frequent adverse reactions at injection site have been reported during clinical trials (pain and burning sensation).

Very rare cases of hypersensitivity reactions ranging from simple skin rash or urticaria to anaphylactic shock have been reported and require discontinuation of treatment.

Cases of erythema, flushing, pruritus and tachycardia have been reported.

There is a risk of liver injury (including fulminant hepatitis, hepatic failure,cholestatic hepatitis, cytolytic hepatitis), particularly in elderly subjects, in young children, in patients with liver disease, in cases of chronic alcoholism, in patients with chronic malnutrition and in patients receiving enzyme inducers. Overdosing may be fatal in these cases.

â–ª Symptoms generally appear within the first 24 hours and comprise: nausea, vomiting, anorexia, pallor, abdominal pain. Overdose, 7.5 g or more of paracetamol in a single administration in adults and 140 mg/kg of body weight in a single administration in children, causes hepatic cytolysis likely to induce complete and irreversible necrosis, resulting in hepatocellular insufficiency, metabolic acidosis and encephalopathy which may lead to coma and death. Simultaneously, increased levels of hepatic transaminases (AST, ALT), lactate dehydrogenase and bilirubin are observed together with decreased prothrombin levels that may appear 12 to 48 hours after administration.

Clinical symptoms of liver damage are usually evident initially after two days, and reach a maximum after 4 to 6 days.

Emergency measures

â–ª Immediate hospitalisation.

â–ª Before beginning treatment, take a tube of blood for plasma paracetamol assay, as soon as possible after the overdose.

â–ª The treatment includes administration of the antidote, N-acetylcysteine (NAC), by the i.v. or oral route, if possible before the 10th hour. NAC can, however, give some degree protection even after 10 hours, but in these cases prolonged treatment is given.

â–ª Symptomatic treatment.

â–ª Hepatic tests must be carried out at the beginning of treatment and repeated every 24 hours. In most cases hepatic transaminases return to normal in one to two weeks with full restitution of liver function. In very severe cases, however, liver transplantation may be necessary.

Pharmacotherapeutic group: OTHER ANALGESICS AND ANTIPYRETICS, ATC code: N02BE01

The precise mechanism of the analgesic and antipyretic properties of paracetamol has yet to be established; it may involve central and peripheral actions.

Paracetamol Alter provides onset of pain relief within 5 to 10 minutes after the start of administration. The peak analgesic effect is obtained in 1 hour and the duration of this effect is usually 4 to 6 hours.

Paracetamol Alter reduces fever within 30 minutes after the start of administration with a duration of the antipyretic effect of at least 6 hours.

Adults:

Absorption:

Paracetamol pharmacokinetics is linear up to 2 g after single administration and after repeated administration during 24 hours.

The bioavailability of paracetamol following infusion of 500 mg and 1 g of Paracetamol Alter is similar to that observed following infusion of 1 g and 2 g propacetamol (corresponding to 500 mg and 1 g paracetamol respectively). The maximal plasma concentration (Cmax) of paracetamol observed at the end of 15-minutes intravenous infusion of 500 mg and 1 g of Paracetamol Alter is about 15 μg/mL and 30 μg/mL respectively.

Distribution:

The volume of distribution of paracetamol is approximately 1 L/kg.

Paracetamol is not extensively bound to plasma proteins.

Following infusion of 1 g paracetamol, significant concentrations of paracetamol (about 1.5 μg/mL) were observed in the Cerebro Spinal Fluid as and from the 20^th minute following infusion.

Metabolism:

Paracetamol is metabolised mainly in the liver following two major hepatic pathways: glucuronic acid conjugation and sulphuric acid conjugation. The latter route is rapidly saturable at doses that exceed the therapeutic doses. A small fraction (less than 4%) is metabolised by cytochrome P450 to a reactive intermediate (N-acetyl benzoquinone imine) which, under normal conditions of use, is rapidly detoxified by reduced glutathione and eliminated in the urine after conjugation with cysteine and mercapturic acid. However, during massive overdosing, the quantity of this toxic metabolite is increased.

Elimination:

The metabolites of paracetamol are mainly excreted in the urine. 90% of the dose administered is excreted in 24 hours, mainly as glucuronide (60-80%) and sulphate (20-30%) conjugates. Less than 5% is eliminated unchanged. Plasma half-life is 2.7 hours and total body clearance is 18 L/h.

Neonates, infants and children

The pharmacokinetic parameters of paracetamol observed in infants and children are similar to those observed in adults, except for the plasma half-life that is slightly shorter (1.5 to 2 h) than in adults. In neonates, the plasma half-life is longer than in infants i.e. around 3.5 hours. Neonates, infants and children up to 10 years excrete significantly less glucuronide and more sulphate conjugates than adults.

Table. Age related pharmacokinetic values (standardized clearance,*CL_std/F_oral (l.h^-1 70 kg^-1), are presented below.

*CL_std is the population estimate for CL

Special populations:

Renal insufficiency

In cases of severe renal impairment (creatinine clearance 10-30 mL/min), the elimination of paracetamol is slightly delayed, the elimination half-life ranging from 2 to 5.3 hours. Posology and method of administration).

Elderly subjects

The pharmacokinetics and the metabolism of paracetamol are not modified in elderly subjects. No dose adjustment is required in this population.

Preclinical data reveal no special hazard for humans beyond the information included in other sections of the SmPC.

Studies on local tolerance of Paracetamol Alter in rats and rabbits showed good tolerability. Absence of delayed contact hypersensitivity has been tested in guinea pigs.

Paracetamol Alter should not be mixed with other medicinal products.

Text for the 50ml and 100ml vials:

Use a 0.8 mm needle and vertically perforate the stopper at the spot specifically indicated.

Before administration, the product should be visually inspected for any particulate matter and discoloration. For single use only. Any unused solution should be discarded.

The diluted solution should be visually inspected and should not be used in presence of opalescence, visible particulate matters or precipitate.