Morfin Kalceks
SUMMARY OF PRODUCT CHARACTERISTICS
1. NAME OF THE MEDICINAL PRODUCT
Morfin Kalceks, 10 mg/ml, solution for injection
2. QUALITATIVE AND QUANTITATIVE COMPOSITION
Morphine hydrochloride 10 mg/ml equivalent to morphine 7.6 mg/ml.
For the full list of excipients, see section 6.1.
3. PHARMACEUTICAL form
Solution for injection.
Clear, colourless or yellowish liquid, pH 3-5.
Osmolarity 0.035‑0.055 Osmol/L.
4. Clinical particulars
4.1 Therapeutic indications
Severe pain conditions which can be adequately managed only with opioid analgesics.
4.2 Posology and method of administration
Administration and posology should be adjusted according to the nature and severity of the pain as well as the general condition of the patient.
Caution should be exercised and the dose initially reduced in morphine treatment of elderly patients and when treating patients with impaired hepatic and renal function.
Individual criteria for the dose are dependent on the patient’s age, weight, pain severity and medical and analgesic history.
Adults: 1-1.5 ml solution for injection (10-15 mg morphine hydrochloride) subcutaneously or intramuscularly 1-3 times daily. In urgent cases morphine can be administered slowly intravenously.
Treatment monitoring
Nausea, vomiting and obstipation can sometimes be counteracted by 0.25-0.5 mg atropine subcutaneously. Respiratory depression can be reversed with naloxone.
4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.
Secretion stagnation in the respiratory tract, respiratory depression, acute liver disease, anxiety conditions during affect by alcohol or hypnotic medicines.
4.4 Special warnings and precautions for use
Causes drug dependence. Take extreme precaution when prescribing this drug. The dose may need reduction in patients with bronchial asthma, upper respiratory tract obstruction, skull injuries, peritoneal dialysis, hypotension associated with hypovolemia, hypothyroidism, impaired hepatic and renal function, inflammatory bowel diseases, pancreatitis, biliary passage or ureter spasms and in the treatment of elderly patients. Caution should be exercised in patients with prostate hypertrophy, myasthenia gravis.
Morphine should not be used in idiopathic pain or in pain with psychopathological characteristics (related to the lack of pain relief).
Morphine alone should not be administered during biliary or renal colic attacks as it may increase the cramp. In these cases morphine should be given in combination with a spasmolytic.
Following encephalitis, the effects of morphine can be enhanced.
Treatment with MAO inhibitors, see section 4.5.
4.5 Interaction with other medicinal products and other forms of interaction
Combinations that should be avoided
Barbiturates
Barbiturates enhance the respiratory depressive effect of opiates and opioids. The combination should therefore be avoided.
Small amounts of alcohol
Small amounts of alcohol can largely increase the weak respiratory depressive effect of morphine. The combination should therefore be avoided.
MAO inhibitors
MAO inhibitors can potentiate the effects of morphine (respiratory depression and hypotension). Serotonin syndrome has been reported during concomitant treatment with pethidine and MAO inhibitors, and the emergence of the same reaction cannot be ruled out during concomitant treatment with morphine and MAO inhibitors.
Combinations that may require dose adjustment
Gabapentin
Attention should be paid to the risk of CNS symptoms in the choice of treatment. If the two products are given concomitantly, consider reducing the gabapentin dose. Patients should therefore be monitored carefully regarding signs of CNS depression such as somnolence, and the gabapentin or morphine dose should be reduced accordingly.
Rifampicin
Rifampicin decreases the plasma concentration of oral morphine strongly enough that higher doses than normal are required for analgesic effect.
Amitriptyline, clomipramine and nortriptyline
Amitriptyline, clomipramine and nortriptyline enhance the analgesic effect of morphine, probably caused by increased bioavailability. Dose adjustment may be necessary.
Combined morphine agonists/antagonists
Combined morphine agonists/antagonists (buprenorphine, nalbuphine, pentazocine) decrease the analgesic effect through competitive inhibition of receptors, which increase the risk of withdrawal symptoms.
Combinations with unclear clinical relevance
Baclofen
The combination of morphine and intrathecal administration of Lioresal caused decreased blood pressure in one patient. The risk for this combination to cause apnoea or other CNS symptoms cannot be excluded.
Benzodiazepines
The combination can increase sedation in the patient. Benzodiazepines can enhance the respiratory depressive effect of opiates which should be taken into consideration.
Hydroxyzine
Concomitant administration of hydroxyzine and morphine can via additive effect cause increased CNS depression and drowsiness. Switching to a non-sedative antihistamine should be considered.
Methylphenidate
Methylphenidate can increase the analgesic effect of morphine. During concomitant administration a reduction of the morphine dose should be considered.
Nimodipine
Nimodipine can increase the analgesic effect of morphine. During concomitant administration a reduction of the morphine dose should be considered.
Ritonavir
Morphine levels can decrease due to induction of glucuronidation by concomitantly administered ritonavir dosed as an antiretroviral medicinal product or pharmacokinetic booster of other protease inhibitors.
4.6 Fertility, pregnancy and lactation
Men and women of childbearing potential
Due to the mutagenic properties of morphine, it should not be administered to men and women of child-producing/child bearing potential unless effective contraception is assured (see section 5.3).
Pregnancy
There are limited amount of data from the use of morphine in pregnant women. Morphine crosses the placenta. Studies in animals have shown reproductive toxicity (see section 5.3).
For this reason, morphine must only be used during pregnancy in cases where the maternal benefit clearly outweighs the risk for the child.
Long term use of morphine during pregnancy may result in a neonatal opioid withdrawal state. Morphine can prolong or shorten the duration of labour. Morphine can produce respiratory depression in the neonate, if it is administered during labour. Infants born to mothers receiving opioid analgesics during late pregnancy or during labour should be monitored for signs of respiratory depression or withdrawal syndrome, and (if necessary) treated with a specific opioid antagonist. Especially during the 2 to 3 hours before expected partum Morfin Kalceks should only be administered on strict indication and following a mother benefit versus baby risk analysis.
Breastfeeding
Morphine is excreted into breast milk, where it reaches higher concentrations than in maternal plasma.
Since clinically relevant concentrations of morphine may be reached in nursing infants, breast-feeding is not recommended (see section 5.2).
Fertility
There are no clinical data on the effects of morphine on male or female fertility.
Morphine had adverse effects on animal fertility (see section 5.3).
4.7 Effects on ability to drive and use machines
Morfin Kalceks treatment can cause impaired ability to react. This should be considered when special attention is required, such as when driving.
Undesirable effects
Approximately 20 % of the patients suffer from nausea and vomiting. Most undesirable effects are dose dependent.
The adverse reactions are presented below in accordance with the MedDRA system organ classification. The frequencies have been assessed in accordance with 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).
Endocrine disorders:
Common: increased ADH release.
Psychiatric disorders:
Uncommon: dysphoria.
Not known: euphoria, sleep, memory and concentration disturbances.
Nervous system disorders:
Common: sedation, dizziness.
Uncommon: respiratory depression, disorientation.
Not known: convulsions, myoclonus.
Eye disorders:
Common: miosis.
Cardiac disorders:
Rare: palpitations, tachycardia, syncope.
Vascular disorders:
Rare: orthostatic hypotension, hypertension, hypotension, peripheral oedema.
Respiratory, thoracic and mediastinal disorders:
Uncommon: bronchoconstriction.
Gastrointestinal disorders:
Common: obstipation, nausea, vomiting.
Not known: dry mouth.
Hepatobiliary disorders:
Uncommon: biliary tract spasm.
Skin and subcutaneous tissue disorders:
Uncommon: pruritus.
Not known: urticaria.
Renal and urinary disorders:
Common: urinary retention.
Uncommon: urinary tract spasm.
General disorders and administration site conditions:
Uncommon: light‑headedness.
Sedation normally decreases after a few days of administration. Nausea and vomiting usually decrease in long term treatment. Spasms in biliary or urinary tract can occur in predisposed persons. The respiratory depressive effect is dose dependent and is rarely a clinical problem.
Dependence and tolerance do normally not cause problems in treatment of severe cancer pain.
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
[To be completed nationally]
4.9 Overdose
Symptoms of overdose: Signs of overdose are pin-point pupils, respiratory depression and low blood pressure. Circulatory disturbances and coma may occur in serious cases.
Ttreatment of overdose: If justified, gastric lavage, charcoal, laxative when orally administered. Respiratory depression caused by morphine intoxication can be reversed with naloxone, initially 0.4 mg for adults (children 0.01 mg/kg) slowly intravenously, the dose is gradually increased if necessary.
Continous infusion of naloxone can sometimes be a useful alternative.
Respirator treatment on when indicated (with PEEP in pulmonary edema). Naloxone cannot replace respirator treatment in serious intoxication. Intravenous fluid (electrolyte solution, glucose), blood gas control, acidosis correction. Symtomatic therapy.
Toxicity: A potential lethal dose for adults (without tolerance development) is usually in the range of 40-60 mg orally (30 mg parenterally). Scopolamine, hypnotics and alcohol potentiate toxic effects.
5. PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Natural opium alkaloids, ATC code: N02AA01
Morphine is an opioid analgesic with potent analgesic effect. The analgesic effect is partly due to an altered pain perception and partly on a raised pain threshold. Morphine probably exerts its analgesic effect at different levels within the CNS. In elderly patients the pain relieving effect of morphine increases. The central nervous system effects of morphine also include respiratory depression, psychiatric symptoms, nausea and vomiting, miosis and antidiuretic hormone release.
The respiratory depressive effect of morphine is caused by the inhibition of the carbon dioxide stimulating effect on the respiratory centre in the medulla oblongata. This effect can lead to respiratory insufficiency in patients with impaired ventilation ability caused by pulmonary disease or other pharmaceuticals. Elderly may be more sensitive to the side effects.
Intoxication with morphine requires respiratory supporting treatment and administration of antidote.
Morphine is metabolised via conjugation to the two main metabolites morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G). Small amounts of morphine-3,6-diglucuronide can also be formed. M3G has a small affinity to opioid receptors, i.e. no documented analgesic effect, but can contribute to excitatory effects. M6G is twice as potent as morphine when systemically administered, and the pharmacologic effects of M6G cannot be separated from those of morphine. During chronic treatment it contributes with a significant part of the analgesic effects of morphine.
As a result of stimulation of dopamine receptors in the “trigger zone” in medulla oblongata, nausea and vomiting can occur. The increased release of antidiuretic hormone contributes to decreased urine volumes during morphine treatment. Morphine increases tonus in smooth muscles in the gastrointestinal tract. This causes obstipation due to a slower passage of food through the gastrointestinal tract. Further the pressure in the biliary passage and the urinary tract increases which makes morphine less suitable in biliary passage or urinary tract spasms.
Morphine has addictive properties and tolerance can develop against the morphine effects. However, normally this causes no problem in treatment of severe pain related to cancer.
5.2 Pharmacokinetic properties
The pharmacokinetics of morphine is not dose dependent.
Absorption
Maximum blood concentration is reached within 10-20 minutes.
Distribution
The volume of distribution of morphine is approximately 3 L/kg with a plasma protein binding of about 35 %. Morphine is widely distributed throughout the body, mainly in the kidneys, liver, lungs and spleen: lower concentrations appear in the brain and the muscles. Morphine crosses the placenta and is excreted into the breast milk (see section 4.6).
Biotransformation
Morphine is metabolised in the liver to the two main metabolites morphine-3-glucuronide (lacks analgesic effect but can contribute with excitatory effects) and morphine-6-glucuronide (M6G) (more potent than morphine itself). Small amounts of morphine-3,6-diglucuronide can also be formed. Morphine and its metabolites undergo enterohepatic circulation.
Elimination
Morphine is primarily eliminated via glucuronidation, and the excretion of unchanged morphine in the urine is 5-10 %. Clearance is approximately 24 mL/min*kg and the half-life is about 2-3 hours.
Up to 10 % of a dose may be excreted via the bile into the faeces.
M6G is excreted via urine, which causes M6G accumulation in renal impairment.
Special population
The morphine bioavailability can increase in liver cancer patients.
Hepatic impairment
Impaired hepatic function influence the elimination of morphine.
Renal impairment
Impaired renal function influence the elimination of morphine. M6G is excreted via the urine. Accumulation of the active metabolite M6G occurs in patients with renal impairment.
5.3 Preclinical safety data
Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology and repeated dose toxicity. There have been no long-term animal studies on the tumorigenic potential of morphine. Effects in non-clinical studies were observed for genotoxicity, and toxicity to reproduction and development.
Mutagenic and tumorigenic potential
There are clearly positive findings available with regards to mutagenicity, which indicate that morphine has a clastogenic effect and that, furthermore, this effect exerts an influence on gametes. Thus, morphine is to be regarded as a mutagenic substance and such an effect may also be assumed in humans.
Reproductive toxicity
Animal studies showed a potential for damage in offspring throughout the entire duration of gestation (CNS malformations, growth retardation, testicular atrophy, changes in neurotransmitter systems and behavioural patterns, dependence). In addition, morphine had an effect on male sexual behaviour and fertility in various animal species.
6. PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Hydrochloric acid (for pH adjustment)
Water for injections
6.2 Incompatibilities
Morphine salts are sensitive to pH changes and can precipitate in alkaline environment. Compounds incompatible with morphine salts include aminophylline, sodium salts of barbiturates, phenytoin and ranitidine hydrochloride.
6.3 Shelf life
3 years.
6.4 Special precautions for storage
Store in the original package in order to protect from light.
Nature and contents of container
Colourless glass ampoules 10 x 1 ml.
5 ampoules are packed in a polyethylene film liner. 2 liners are packed in a carton.
6.6 Special precautions for disposal and other handling
Splashes on the skin and in the eyes can cause burning pain, redness and pruritus. Avoid direct contact with the product.
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
7. MARKETING AUTHORISATION HOLDER
[To be completed nationally]
8. MARKETING AUTHORISATION NUMBER(S)
[To be completed nationally]
9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
Date of first authorisation: [To be completed nationally]
10. DATE OF REVISION OF THE TEXT
21 September 2016
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