Paracetamol

Paracetamol 10 mg/ml Solution for Infusion

One ml contains 10 mg paracetamol

One 50ml vial contains 500mg paracetamol.

One 100ml vial contains 1000mg paracetamol.

Excipient with known effect

Sodium 0.994mg/ml

For the full list of excipients, see section 6.1

Solution for infusion.

The solution is clear.

Paracetamol 10 mg/ml Solution for Infusion 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 use.

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

The 100 ml vial is restricted to adults, adolescents, and children weighing more 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 (see section 5.2).

**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 (See section 5.2).

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

The maximum daily dose must not exceed 3 g (see section 4.4).

Method of administration

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

Patients weighing ≤ 10 kg:

• The glass vial/bag of paracetamol, solution for infusion, 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• The volume to be administered should be withdrawn from the vial/bag and diluted in a 0.9% sodium chloride solution or 5% glucose solution up to one tenth (one volume paracetamol, solution for infusion, into nine volumes diluent) and administered over 15 minutes

• 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 infusion applies particularly for central route infusions, in order to avoid air embolism

Text for the 50ml vial:

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

Hypersensitivity to the active substance or to propacetamol hydrochloride (prodrug of paracetamol) or to any of the excipients listed in section 6.1.

In cases of severe hepatocellular insufficiency.

Warnings

It is recommended that a suitable analgesic oral treatment be used as soon as this route of administration 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 those recommended entail the risk of very serious liver damage. Clinical signs and symptoms 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 (See section 4.9).

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 (see section 4.2).

Precautions for use

Paracetamol should be used with caution in cases of :

• hepatocellular insufficiency,

• severe renal insufficiency (creatinine clearance ≤30 mL/min) (see sections 4.2 and 5.2),

• chronic alcoholism,

• chronic malnutrition (low reserves of hepatic glutathione),

• dehydration.

This medicine contains less than 1 mmol sodium (23 mg) per 50ml vial and 100ml vial, that is to say essentially 'sodium-free'.

• Probenecid causes an almost 2-fold reduction in clearance of paracetamol by inhibiting its conjugation with glucuronic acid. A reduction in the paracetamol dose should be considered if it is to be used concomitantly with probenecid.

• Salicylamide may prolong the elimination t½ of paracetamol.

• Caution should be taken with the concomitant intake of enzyme-inducing substances (see section 4.9). Concomitant use of paracetamol (4 g per day for at least 4 days) with oral anticoagulants may lead to slight variations of INR values. In this case, increased monitoring of INR values should be conducted during the period of concomitant use as well as for 1 week after paracetamol treatment has been discontinued.

Pregnancy

A large amount of data on pregnant women indicate neither malformative, nor feto/neonatal toxicity. Epidemiological studies on neurodevelopment in children exposed to paracetamol in utero show inconclusive results. If clinically needed, paracetamol can be used during pregnancy however it should be used at the lowest effective dose for the shortest possible time and at the lowest possible frequency.

Breast-feeding

After oral administration, paracetamol is excreted into breast milk in small quantities. No undesirable effects on nursing infants have been reported. Consequently, Paracetamol 10 mg/ml Solution for Infusion may be used in breast-feeding women.

Not relevant.

The frequency of adverse events listed below is defined using the following convention:

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).

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.

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 or search for MHRA Yellow Card in the Google Play or Apple App Store.

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.

Symptoms generally appear within the first 24 hours and comprise: nausea, vomiting, anorexia, pallor and abdominal pain.

Overdose, 7.5 g or more of paracetamol in a single administration in adults or 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

Immediate hospitalisation.

Before beginning treatment, take a blood sample for plasma paracetamol assay, as soon as possible after the overdose.

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 of protection even after 10 hours, but in these cases prolonged treatment is given.

Symptomatic treatment.

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 return of normal 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 10 mg/ml Solution for Infusion 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 10 mg/ml Solution for Infusion 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 500mg and 1 g of Paracetamol 10 mg/ml Solution for Infusion is similar to that observed following infusion of 1g and 2 g propacetamol (containing 500mg and 1 g paracetamol respectively). The maximal plasma concentration (Cmax) of paracetamol observed at the end of 15-minutes intravenous infusion of 500mg and 1 g of Paracetamol 10 mg/ml Solution for Infusion is about 15μg/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 cerebrospinal fluid at and after the 20th minute following infusion.

Biotransformation

Paracetamol is metabolised mainly in the liver following two major hepatic pathways: glucuronic acid conjugation and sulfuric 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 within 24 hours, mainly as glucuronide (60-80%) and sulfate (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 sulfate conjugates than adults.

Table - Age related pharmacokinetic values (standardised clearance, *CLstd/Foral (L.h-1 70kg-1)

*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. For the glucuronide and sulfate conjugates, the elimination rate is 3 times slower in subjects with severe renal impairment than in healthy subjects. Therefore when giving paracetamol to patients with severe renal impairment (creatinine clearance ≤30 mL/min), the minimum interval between each administration should be increased to 6 hours (see section 4.2. 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 10 mg/ml Solution for Infusion in rats and rabbits showed good tolerability. Absence of delayed contact hypersensitivity has been tested in guinea pigs.

Conventional studies using the currently accepted standards for the evaluation of toxicity to reproduction and development are not available.

Cysteine hydrochloride monohydrate

Disodium phosphate dihydrate

Hydrochloric acid 1M (for pH-adjustment)

Mannitol

Sodium hydroxide 1M (for pH-adjustment)

Water for Injections

This medicinal product must not be mixed with other medicinal products except for dilution with 0.9% sodium chloride or 5% glucose solution

24 months.

From a microbiological point of view, unless the method of opening precludes the risk of microbial contamination, the product should be used immediately. If not used immediately, in-use storage times and conditions are the responsibility of the user.

Store below 30°C. Protect from light. Store in the original package. Do not refrigerate or freeze.

50ml and 100 ml Type II colourless glass vial with bromobutyl stopper and an aluminium cap.

Pack size: pack of 1, 10 or 12 vials.

Not all pack sizes may be marketed.

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

Accord Healthcare Limited

Sage House

319 Pinner Road

North Harrow

Middlesex

HA1 4HF

PL 20075/0701

01/02/2011

10/01/2020

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