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Ketamin Abcur

Document: Ketamin Abcur solution for injection ENG SmPC change


SUMMARY OF PRODUCT CHARACTERISTICS


1. NAME OF THE MEDICINAL PRODUCT


Ketamin Abcur 10 mg/ml, solution for injection

Ketamin Abcur 50 mg/ml, solution for injection


2. QUALITATIVE AND QUANTITATIVE COMPOSITION


Each ml solution for injection contains ketamine hydrochloride equivalent to 10 mg ketamine.

1 ampoule of 5 ml contains ketamine hydrochloride equivalent to 50 mg ketamine.


Each ml solution for injection contains ketamine hydrochloride equivalent to 50 mg ketamine.

1 ampoule of 5 ml contains ketamine hydrochloride equivalent to 250 mg ketamine.

1 ampoule of 10 ml contains ketamine hydrochloride equivalent to 500 mg ketamine.


Excipients with known effect: contains 0,29 mmol sodium (6,6 mg) per ml sodium.

For the full list of excipients, see section 6.1.


3. PHARMACEUTICAL form


Solution for injection (injection).

Clear colourless solution


4. Clinical particulars


4.1 Therapeutic indications


Induction and maintenance of anaesthesia for diagnostic and surgical procedures either as a single anaesthetic agent or in combination with other anaesthetic agents. Prior to the induction or to supplement regional anaesthesia.


4.2 Posology and method of administration


Ketamin Abcur should only be administered by or under supervision of medically qualified anaesthetists. Equipment to ensure the vital functions should be available.

Premedication: Atropine or glycopyrrolate should be given preoperatively to inhibit mucus secretion. Benzodiazepine derivate such as midazolam, as premedication (intravenous or rectal), can be given to supress the initial hyperkinetic circulation and reduce the frequency of anxiety during awakening.


Posology


Intramuscular:For intramuscular administrationthe higher strength, Ketamin Abcur 50 mg/ml, should be chosen to minimize the volume.

i.m. injection

Dose (mg/kg body weight)

Onset time(min)

Duration(min)

Induction

10.0 (6.5–13.5)

3-5

12-25

Maintenance

½ the induction dose


Intravenous: Administration of the initial intravenous dose should be slow (at least 60 seconds). More rapid administration may result in transient respiratory depression.


i.v. injection

Dose (mg/kg body weight)

Onset time (min)

Duration(min)

Induction

2.0 (1.0–4.5)

1

5-15

Maintenance

½ the induction dose or transition to infusion. See below.


Conversion table: Dose in mg/kg body weight to dose in ml/kg body weight


Dose

mg/kg body weight

Dose

ml/kg body weight


Ketamin Abcur 10 mg/ml

Dose

ml/kg body weight


Ketamin Abcur 50 mg/ml

1.0

0.10

0.02

2.0

0.20

0.04

4.5

0.45

0.09

6.5

0.65

0.13

10.0

1.00

0.20

13.5

1.35

0.27

Infusion: Infusion gives a more even course of anaesthesia. The total dose of ketamine is often lower than with intermittent injections and awakening occurs faster. During ventilation with oxygen/nitrous oxide, a dose of ketamine in the lower range may be sufficient.


Infusion

Dose

Induction

2.0-6.0 mg/kg body weight

Maintenance

2.0-6.0 mg/kg body weight and hour

The dose above is equivalent to about 1 drop/kg body weight and minute of ketamine 1 mg/ml solution for infusion.


Dosing in obstetrics: For use in obstetrics, during vaginal delivery or cesarean section, an intravenous dose in the interval 0.2-1.0 mg/kg is recommended, see section 4.6.


Dosing in hepatic impairment: Dose reduction should be considered for patients with cirrhosis or hepatic impairment for other reasons (see section 4.4).


Dosing in renal impairment
Dose reduction is usually not required.


Paediatric population

The safety and efficay in children below 18 years have not yet been established.


Combination with other anaesthetic agents: Ketamine can advantageously be combined with benzodiazepine derivates, such as midazolam. Ketamine and midazolam can be mixed in the same infusion (10 ml Ketamin Abcur 50 mg/ml + 7.5 ml midazolam 5 mg/ml per 500 ml solution for infusion).


Induction (i.v. injection)

ketamine

2 mg/kg body weight

midazolam

0.15 mg/kg kroppsvikt

Maintenance (continuous infusion)

ketamine

1 mg/kg bodyweight and hour

midazolam

0.075 mg/kg body weight and hour

Method of administration


For instructions on dilution of the medicinal product before administration, see section 6.6.


4.3 Contraindications


Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.


Patients whom an elevation of blood pressure would constitute a serious hazard.

Eclampsia or pre-eclampsia.


4.4 Special warnings and precautions for use


Ketamin Abcur should be used with caution in patients with:


The induction of the anaesthesia is accompanied by occasional tachycardia, elevation of the blood pressure and cardiac output, which return to baseline within 15 minutes after the injection. The median peak rise of the blood pressure in clinical studies has ranged from 20 to 25 percent of the initial values. Depending on the condition of the patient, this elevation of the blood pressure may be considered an adverse reaction or a beneficial effect of ketamine.


After outpatient anaesthesia the patient should be accompanied home and should not drink alcohol for the next 24 hours.


Ketamine is metabolised in the liver and hepatic clearance is required for termination of the clinical effects. A prolonged duration of action may occur in patients with cirrhosis or other types of liver impairment. Dose reductionshould be considered in these patients.

Liver toxicity has been reported in patients after prolonged use (>3 days).


Ketamine has been given as a single agent with good safety when the ventricle has not been emptied. As the need for additional anaesthetics or muscle relaxants cannot always be predicted it is recommended that the patient fasts for 4-6 hours prior to surgery to prevent aspiration. Because pharyngeal reflexes usually remains active, mechanical stimulation of the pharynx should be avoided unless muscle relaxants with proper attention are used.


Cases of cystitis including haemorrhagic cystitis have been reported in patients being given ketamine on a long term basis (outside the current indication). This adverse reaction develops in patients receiving long term ketamine treatment after a time ranging from 1 month to several years.


Abuse and dependence

Ketamine has been reported as being a drug of abuse. Reports suggest that ketamine produces a variety of symptoms including, but not limited to, flashbacks, hallucinations, dysphoria, anxiety, insomnia or disorientation. Cases of cystitis, including haemorrhagic cystitis have also been reported. Dependence and tolerance may develop in individuals with a history of drug abuse and dependence. Therefore ketamine should be prescribed and administered with caution.


Ketamin Abcur contains sodium

10 mg/ml: 1 ampoule of 5 ml contains less than 1 mmol sodium (23 mg), i.e. essentially ‘sodium-free’,


4.5 Interaction with other medicinal products and other forms of interaction


Ketamine may increase the effect of coadministered opioids causing increased CNS- and/or respiratory depression.


Theophylline

Since there is clinicalandexperimentalevidence ofloweredseizure thresholdat thecombination oftheophyllineandketamine combination withtheophyllineshould be avoided.Unpredictableextensor-type seizureshave been reported withconcurrent administration ofthese agents.

Neuromuscular blockers

Ketamine may potentiate and prolong the effect of neuromuscular blocking agents (e g suxametonium and atracurium) causing prolonged muscle relaxation and/or respiratory depression.


Diazepam

Premedication with diazepam prolongs the half-life of ketamine with enhanced efficacy as a result. The combination may require dose adjustment.


Vasopressin

At concurrent administration of ketamine and vasopressin synergetic increase in the blood pressure been observed.


Barbiturates, narcotics, inhalation anaesthetics, alcohol, muscular relaxants

Prolonged recovery time may occur if barbiturates, narcotics and inhalation anaesthetics are used concurrently with ketamine. Concurrent use of ketamine (especially in high doses or when rapidly administered) with halogenated anaesthetics can increase the risk of developing bradycardia, hypotension or decreased cardiac output.

Concurrent administration of ketamine and other sedatives (e.g. ethanol, phenothiazines, sedating H1-blockers or muscle relaxants) can potentiate CNS depression and/or increase risk of respiratory depression. Reduced doses of ketamine may be required with concurrent administration of other anxiolytics, sedatives and hypnotics. Ketamine has been reported to antagonise the hypnotic effect of thiopental.


Thyroid hormones

Patients taking thyroid hormones have an increased risk of developing hypertension and tachycardia when given ketamine.


Antihypertensive agents

Concomitant use of antihypertensive agents and ketamine increase the risk of developing hypotension.


Medicinal products that inhibit the enzyme activity of CYP3A4 usually decrease hepatic clearance which may cause increased plasma concentrations of CYP3A4 substrates such as ketamine. A dose reduction of ketamine may be required in case of concomitant administration with CYP3A4 inhibitors (e g itraconazole, fluconazole, clarithromycin, erythromycin, verapamil, diltiazem).


Medicinal products that induce the enzyme activity of CYP3A4 usually increase hepatic clearance which may cause decreased plasma concentrations of CYP3A4 substrates such as ketamine. A dose increase of ketamine may be required in case of concomitant administration with CYP3A4 inducers (eg phenytoin, carbamazepine, St John´s Wort).


4.6 Fertility, pregnancy and lactation


Pregnancy

No controlled clinical studies in pregancy have been conducted. The safe use in pregnancy has not been established, and such use is not recommended, with the exception of administration during surgery for abdominal or vaginal delivery. Ketamine readily crosses the placenta.Some neonates exposed to ketamine at maternal intravenous doses >1.5 mg/kg during delivery have experienced respiratory depression and low Apgar scores requiring newborn resuscitation. Marked increases in maternal blood pressure and uterine tone have been observerd at intravenous doses greater than 2 mg/kg.


Breastfeeding

Ketamine is excreted in the breast milk, but the risk for the infant seems unlikely with therapeutic doses. Since necessary data is lacking the use cannot be recommended.


4.7 Effects on ability to drive and use machines


After treatment with ketamine the ability to react may be impaired. This should be considered when alertness is required, e.g. when driving a car.

Patients should not drive motor vehicles or operate machinery at least 24 hours after anaesthesia with ketamine.


Undesirable effects


The adverse reactions are mostly related to dose and rate of injection and are reversible. CNS adverse events are more common if Ketamin Abcur is given as a single anaesthetic.


The following adverse reactions have been observed and reported in treatment with ketamine.

Frequency description: 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) and not known (frequency cannot be estimated from available data).


MedDRA

system organ class database

Common

(1/100, <1/10)

Uncommon (1/1 000, <1/100)

Rare

(1/10 000, <1/1 000)

Not known (frequency cannot be estimated from available data)

Immune system disorders

anaphylactic reaction*

Metabolism and nutrition disorders

anorexia

Psychiatric disorders

hallucination, abnormal dreams, nightmare, confusion, agitation, abnormal behaviour

anxiety

delirium*, flashback*, dysphoria*, insomnia, disorientation

Nervous system disorders

nystagmus, tonic clonic movements


Eye disorders

diplopia

increased intraocular pressure

Cardiac disorders

increased blood pressure, increased heart rate

bradycardia, arrhythmia

Vascular disorders

hypotension

Respiratory, thoracic and mediastinal disorders

increased respiratory rate

respiratory depression, laryngospasm

obstructive airway disorder*, apnoea*

Gastrointestinal disorders

nausea, vomiting, salivary hypersecration*


Hepatobilary disorders


abnormal liver function test

drug induced liver damage**

Skin and subctaneous tissue disorders

erythema, rash mobilliform

exanthem

Musculoskeletal and connective tissue disorders

increased muscle tonus

General disorders and administration site conditions

injection site pain, injection site rash


*AE frequency estimated from post-marketing safety database

** After prolonged use (>3 days) or drug abuse


Awakening from the anaesthesia is often accompanied by vivid dreams, with or without psychomotor activity, which can be manifested in nightmares or hallucinations, confusion, emergence delirium (often with dissociative or floating sensation) and irrational behaviour. The incidence of these reactions is reduced by combination of Ketamin Abcur and benzodiazepine derivate. Transient respiratory depression due to CNS disorders can be seen at intravenous induction and is dependent on dose and rate of injection.



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 national reporting system listed in Appendix V*.


4.9 Overdose


Clinical signs of overdose are convulsions, cardiac arrest and respiratory depression.


Respiratory depression should be treated with assisted or controlled ventilation until adequate spontaneous respiration is restored.


Convulsion should be treated with intravenous diazepam. If this treatment does not give the desired result is intravenous administration of phenytoin or thiopental recommended.


No specific antidote is available.


5. PHARMACOLOGICAL PROPERTIES


5.1 Pharmacodynamic properties


Pharmacotherapeutic group: general anaesthetic, ATC code: N01AX03


Ketamin Abcur contains the active substance ketamine in racemic form. Ketamine gives a dissociative anaesthesia by selectively interrupting association pathways in the brain. The analgesic effect in sub anaesthetic doses is probably due to interactions with biogenic amine- and endogenous opioid systems. Ketamine do not usually affect the reflex of the pharynx and larynx and the muscle tone remains normal or increases slightly. Cardiovascular and respiratory stimulating effects admit ketamine to be given to high-risk patients in hypovolemic shock. The bronchodilation action of ketamine allows use in patients with asthma bronchiale and the respiratory treatment of status astmaticus. The effect on the secretion and the gastrointestinal tract is attenuated by premedication with anticholinergics. The analgesic effect can be utilized as a complement to regional anaesthesia or in mass casualty situations/disasters. Ketamine is clinically compatible with the commonly used anaesthetics and muscle relaxants provided that respiration is maintained.

An intravenous dose of 2.0 mg/kg body weight provides surgical anaesthesia within one minute after injection and the anaesthetic effect persists for 5-15 minutes. Intramuscular dosing 10.0 mg/kg body weight gives surgical anaesthesia within 3-5 minutes after injection with a duration of 12-25 minutes. To achieve prolonged anaesthesia or analgesia Ketamin Abcur may be given via drip infusion or syringe pump for even administration. Intravenous or intramuscular administration can be repeated.


5.2 Pharmacokinetic properties


Absorption

Ketamine is rapidly absorbed following intramuscular administration.The bioavailability following intramuscular administration is 90 %.


Distribution

The binding to plasma proteins is about 50 %. The lipid solubility is high. Ketamine easily passes the placenta and is quickly distributed to highly perfused tissues (e g heart, lung and brain), followed by muscle tissues and then fat. Ketamine has a biphasic plasma profile with a distribution phase lasting for 45 minutes and with distribution half-life of 10-15 minutes, which clinically corresponds to the anaesthetic effect. Maximum plasma concentrations are approximately 0.6-0.7 µg/ml and levels in cerebrospinal fluid are approximately 0.2 µg/ml 1-2 hours after an intravenous ketamine dose of 1 mg/kg.


Biotransformation

Degradation of ketamine occurs in the liver. The plasma half-life is about 80 minutes in adults, slightly shorter for children.

Ketamine is N-demetylated in the liver (via the cytochrome P450 system) and hydroxylated on the cyclohexane ring resulting in water soluble conjugates that are excreted in the urine. CYP3A4 is the primary enzyme responsible for N-demethylation of ketamine to norketamine in human liver microsomes, and the enzymes CYP2B6 and CYP2C9 contribute to a small extent. Additional oxidation occurs with formation of cyclohexanon derivates. The nonconjugated N-demethylated metabolite has been demonstrated to have less than 1/6 of the potency of ketamine. The nonconjugated demethylcyclohexanone derivative has been demonstrated to have less than 1/10 of the potency of ketamine.


Elimination

Results from adults show that approximately 91% of the dose is recovered in urine and faeces.


5.3 Preclinical safety data


There are no preclinical data considered relevant to clinical safety beyond data included in other sections of this Summary of Product Characteristics.


6. PHARMACEUTICAL PARTICULARS


6.1 List of excipients


10 mg/ml:

Sodium chloride

Water for injections


50 mg/ml:

Water for injections


6.2 Incompatibilities


Ketamin Abcur is chemically incompatible with barbiturates and diazepam because of formation of precipitate. Therefore, these should not be mixed in the same syringe or infusion fluid.


This medicinal product must not be mixed with other medicinal products except those mentioned in section 6.6.


6.3 Shelf life


Before first opening:3 years

After opening: Chemical and physical in-use stability has been demonstrated for 48 hours at 25°C. From microbiological point of view, the product should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2 to 8°C, unless reconstitution/dilution has taken place in controlled and validated aseptic conditions.


6.4 Special precautions for storage


No special storage conditions.


Nature and contents of container


Ketamin Abcur 10 mg/ml: 5 ml glass ampoules (type I) in boxes of 5, 10, 20, 50 or 100 ampoules.

Ketamin Abcur 50 mg/ml: 5 ml glass ampoules (type I) in boxes of 5, 10, 20, 50 or 100 ampoules.

10 ml glass ampoules (type I) in boxes of 5, 10, 20, 50 or 100 ampoules.


Not all pack sizes may be marketed.


6.6 Special precautions for disposal and other handling


Ketamin Abcur can be diluted with 50 mg/ml (5%) glucose solution and 9 mg/ml (0.9%) sodium chloride.


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


7. MARKETING AUTHORISATION HOLDER


Abcur AB
Box 1452

251 14 Helsingborg

Sweden


8. MARKETING AUTHORISATION NUMBER(S)


<[To be completed nationally]>


9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION


10. DATE OF REVISION OF THE TEXT


22 December 2015


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