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Document: Novastan concentrate for solutionfor infusion ENG SmPC change

• Novastan concentrate for solution for infusion SmPC
• Novastan concentrate for solutionfor infusion ENG SmPC

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summary of the product characteristics

Novastan 100 mg/ml concentrate for solution for infusion.

2. QUALITATIVE AND QUANTITATIVE COMPOSITION

1 ml concentrate for solution for infusion contains 100 mg argatroban monohydrate.

1 Vial with 2.5 ml concentrate for solution for infusion contains 250 mg argatroban monohydrate.Final concentration after dilution as recommended is 1 mg/ml (see section 6.6).

Excipients: 1 ml solution contains 400 mg ethanol (50% by volume) and 300 mg sorbitol.

For a full list of excipients, see section 6.1.

3. PHARMACEUTICAL FORM

Concentrate for Solution for Infusion.

Clear colourless to pale yellow solution.

4. CLINICAL PARTICULARS

4.1 Therapeutic indications

Anticoagulation in adult patients with heparin-induced thrombocytopenia type II who require parenteral antithrombotic therapy.

The diagnosis should be confirmed by the HIPAA (heparin induced platelet activation assay) or an equivalent test. However, such confirmation must not delay the start of treatment.

4.2 Posology and method of administration

Initial Dosage

Treatment with Novastan should be initiated under the guidance of a physician with experience in coagulation disorders.

The initial dosage in adult patients without hepatic impairment in HIT type II is 2 microgram/kg/min, administered as a continuous infusion (see Method of Administration). Before Novastan is administered, heparin therapy should be discontinued and a baseline aPTT value obtained.

Standard recommendations

Monitoring:

In general, therapy with Novastan is monitored using the activated partial thromboplastin time (aPTT).

Tests of anticoagulant effects (including the aPTT) attain steady-state levels typically within 1‑3 hours following initiation of Novastan.

The target range for steady-state aPTT is 1.5 to 3.0 times the initial baseline value, but not exceeding 100 seconds.

Dose adjustment may be required to attain the target aPTT (see Dose Modifications).

aPTT should be checked two hours after the start of the infusion to confirm that the aPTT is within the desired therapeutic range. Thereafter, the aPTT should be monitored at least once per day.

Dose modifications:

After the initial dose of Novastan, the dose can be adjusted based on the clinical course until the steady-state aPTT is within the desired therapeutic range (1.5 to 3.0 times the initial baseline value but not exceeding 100 seconds). In case of an elevated aPTT (greater than 3 times baseline or 100 seconds), the infusion should be discontinued until the aPTT is within the desired range of 1.5 to 3 times baseline (typically within 2 hours of discontinuation of infusion), and the infusion restarted at one half of the previous infusion rate. The aPTT should be checked again after 2 hours.

The maximum recommended dose is 10 microgram/kg/min. The maximum recommended duration of treatment is 14 days, although there is limited clinical experience of administration for longer periods (see section 5.1).

Method of administration

Novastan is supplied as a concentrate (250 mg/2.5 ml) which must be diluted 100‑fold prior to infusion to a final concentration of 1 mg/ml (see section 6.6).

Standard infusion rates for the 2 microgram/kg/min recommended initial dosage (1 mg/ml final concentration) are detailed in the table below. The standard infusion rates for patients with moderate hepatic impairment (Child-Pugh Class B), after cardiac surgery and critically ill patients with a starting infusion rate of 0.5 microgram/kg/min are also detailed in the table below:

Additional Information on Special Populations:

Elderly

The standard initial dosage recommendations for use in adults are applicable to elderly patients.

Paediatric population

Limited data from a prospective clinical study in 18 children (neonates to 16 years old) and published data is available. The safe and effective dose or the effective target range for aPTT or activated clotting time (ACT)of Novastan has not been clearly established in this patient population. Currently available data are described in Section 5.1 and 5.2 but no recommendation on a posology can be made.

Renal impairment

The standard initial dosage recommendations for use in adults are applicable to patients with renal impairment (see section 5.2).

Limited data is available from the use of Novastan in haemodialysis. Based on the data, therapy could be initiated with an initial bolus (250 microgram/kg) followed by continuous infusion of 2 microgram/kg/min. The infusion is stopped 1 hour before the end of the procedure. The target ACT range is 170-230 seconds (measured using the Haemotec device). In patients that are already being treated with Novastan no bolus dose is required.

Novastan clearance by high flux membranes used during haemodialysis and continuous venovenous haemofiltration was clinically insignificant.

Hepatic impairment

For patients with moderate hepatic impairment (Child-Pugh Class B), an initial dose of 0.5 microgram/kg/min is recommended (see section 4.4 and section 5.2). The aPTT should be monitored closely and the dosage should be adjusted as indicated clinically. Novastan is contra-indicated in patients with severely impaired liver function.

Patients with HIT Type II after cardiac surgery and critically ill patients

Limited data is available from the use of Novastan in patients with HIT Type II after cardiac surgery and critically ill patients / intensive care unit (ICU)patients with (multiple) organ system failure. Based on the data therapy could be initiated with a starting infusion rate of 0.5 microgram/kg/min (maximum 10 microgram/kg/min) and adjusted to the target aPTT range of 1.5 to 3.0 times baseline value (not exceeding 100 seconds).

In critically ill/ICU patients with severe (multiple) organ failure (as assessed by SOFA-II APACHE-II or comparable scores) a reduced maintenance dose is recommended.

The clinical status of the patient, especially acute changes in hepatic function, should be taken into account and the infusion rate should be carefully adjusted to maintain the aPTT in the desired range.

An increase in the frequency of monitoring is recommended to ensure the target aPTT values are achieved and maintained.

Patients with HIT Type II undergoing percutaneous coronary intervention (PCI)

Limited data is available from the use of Novastan in patients with HIT Type II undergoing percutaneous coronary intervention. Based on the data, when there is no alternative, therapy could be initiated with a bolus dose of 350 microgram/kg over 3 to 5 minutes followed by an infusion dose of 25 microgram/kg/min. ACT should be checked 5 to 10 minutes after the bolus dose is completed. The procedure may proceed if the ACT is greater than 300 seconds. If the ACT is below 300 seconds, an additional bolus dose of 150 microgram/kg should be administered, the infusion rate be increased to 30 microgram/kg/min, and the ACT should be checked 5 to 10 minutes later. If the ACT is higher than 450 seconds, the infusion rate should be decreased to 15 microgram/kg/min and ACT values be checked 5 to 10 minutes later. Once a therapeutic ACT between 300 to 450 seconds has been achieved, the infusion dose should be continued for the duration of the procedure. ACT measurements were recorded using both Haemotec and Haemochrom devices.

The efficacy and safety of Novastan use in combination with GPIIb/IIIa inhibitors has not been established.

Body Weight (kg)	For ACT 300-450 seconds Initial Dosage 25 mcg/kg/min			If ACT <300 seconds Dosage Adjustment† 30 mcg/kg/min			If ACT >450 seconds Dosage Adjustment 15 mcg/kg/min
	Bolus Dose (mcg)	Infusion Dose (mcg/min)	Infusion Rate (ml/hr)	Bolus Dose (mcg)	Infusion Dose (mcg/ min)	Infusion Rate (ml/hr)	Infusion Dose (mcg/min)	Infusion Rate (ml/hr)
50	17500	1250	75	7500	1500	90	750	45
60	21000	1500	90	9000	1800	108	900	54
70	24500	1750	105	10500	2100	126	1050	63
80	28000	2000	120	12000	2400	144	1200	72
90	31500	2250	135	13500	2700	162	1350	81
100	35000	2500	150	15000	3000	180	1500	90
110	38500	2750	165	16500	3300	198	1650	99
120	42000	3000	180	18000	3600	216	1800	108
130	45500	3250	195	19500	3900	234	1950	117
140	49000	3500	210	21000	4200	252	2100	126

NOTE: Novastan concentrate is diluted before use to 1 mg/ml = 1000 microgram (mcg)/ml

† Additional IV bolus dose of 150 mcg/kg should be administered if ACT <300 seconds.

Specific dosing information on patients with hepatic impairment undergoing PCI is not available. Therefore, the use of Novastan for treatment of patients with hepatic impairment requiring PCI is not recommended.

Recommendations for use in patients scheduled for a conversion to oral anticoagulation

Use of oral anticoagulants (of the coumarin type) should be delayed until substantial resolution of thrombocytopaenia (e.g. platelets >100 x 10⁹/L) to avoid coumarin associated microvascular thrombosis and venous limb gangrene. The intended maintenance dose should be started with no loading dose.

For both the Quick and Owren type PT assays;

Co-therapy of Novastan and oral anticoagulants (of the coumarin type) is recommended for a minimum of 5 days. INR should be measured daily while Novastan and oral anticoagulants are co-administered. The target value for INR should be within the therapeutic range for co-therapy according to the type of assay used (see above) for at least 2 days before Novastan is discontinued.

The INR measurement should be repeated 4 to 6 hours after discontinuation of Novastan. If the repeat INR is below the desired therapeutic range, the infusion of Novastan should be resumed and the procedure repeated daily until the desired therapeutic range on oral anticoagulants alone is reached.

For doses greater than 2 microgram/kg/min, the relationship between INR on oral anticoagulants alone or INR on oral anticoagulants plus Novastan is less predictable. With such higher doses, the dose of Novastan should be temporarily reduced to 2 microgram/kg/min in order to improve the prediction of INR on oral anticoagulants alone (see above). The INR on Novastan and oral anticoagulants should be measured 4 to 6 hours after reduction of the Novastan dose.

4.3 Contraindications

Novastan is contraindicated

• In patients with uncontrolled bleeding

• Hypersensitivity to argatroban or to any of the excipients

• Severe hepatic impairment.

4.4 Special warnings and precautions for use

Novastan causes a generally increased tendency to bleeding. An unexplained fall in haematocrit, fall in blood pressure, or any other unexplained symptom should lead to consideration of a haemorrhagic event.

Novastan should be used with extreme caution in disease states and other circumstances in which there is an increased danger of haemorrhage. These include treatment for severe hypertension; diabetic retinopathy;immediately following lumbar puncture; spinal anaesthesia; major surgery, especially involving the brain, spinal cord, or eye; haematological conditions associated with increased bleeding tendencies such as congenital or acquired bleeding disorders and gastrointestinal lesions such as ulcerations.

Parenteral anticoagulants: All parenteral anticoagulants should be discontinued before administration of Novastan. When Novastan is to be started after cessation of heparin therapy, sufficient time should be allowed for the effect of heparin on the aPTT to decrease prior to start of Novastan therapy (about 1-2 hours).

Hepatic Impairment: Caution should be exercised when administering Novastan to patients with hepatic disease, by starting with a lower dose and carefully titrating until the desired level of anticoagulation is achieved (see section 4.2). Also, upon cessation of Novastan infusion in the hepatically-impaired patient, full reversal of anticoagulant effects may require longer than 4 hours due to decreased clearance of argatroban.

Laboratory Tests: Measurements of aPTT are recommended for monitoring the infusion. Although other plasma coagulation tests including prothrombin time (PT, expressed for example as the International Normalized Ratio (INR)), the activated clotting time (ACT) and thrombin time (TT) are affected by Novastan; the therapeutic ranges for these tests have not been defined (with the exception of ACT). Plasma argatroban concentrations also correlate well with the anticoagulant effects.

The concomitant use of Novastan and oral anticoagulants of the coumarin type may result in prolongation of the PT (INR) beyond that produced by oral anticoagulants alone. Refer to section 4.2 for alternative approaches for monitoring concurrent Novastan and oral anticoagulants therapy.

Ethanol: Novastan contains ethanol. A 70 kg patient administered the maximum recommended daily dose (10 microgram/kg/min) would receive a dose of approximately 4 g ethanol per day.

This medicinal product contains sorbitol. Patients with rare hereditary problems of fructose intolerance should not use this medicinal product.

There is no specific antidote to Novastan.

4.5 Interaction with other medicinal products and other forms of interaction

Concomitant use with antiplatelet agents, thrombolytics, and other anticoagulants may increase the risk of bleeding.

Oral anticoagulant agents:Pharmacokinetic drug interactions between Novastan and warfarin (7.5 mg single oral dose) have not been demonstrated. However, the concomitant use of Novastan and warfarin (5-7.5 mg initial oral dose followed by 2.5-6 mg/day orally for 6 to 10 days) results in an increase of the International Normalized Ratio (INR). Refer to section 4.2 for recommendations for managing the switch from Novastan to oral anticoagulation.

Thrombolytics, anti-platelet and other agents: The safety and effectiveness of Novastan with thrombolytic agents have not been established.

The risks for interaction with argatroban have not been evaluated. Caution is needed when concomitant medicinal products are commenced for the first time.

As Novastan contains ethanol, an interaction with metronidazol or disulfiram cannot be excluded.

4.6 Fertility, pregnancy and lactation

Pregnancy

There are no adequate data from the use of Novastan in pregnant women. The effect of argatroban on reproduction has been incompletely studied in animal experiments, as technical issues have limited systemic exposure (see section 5.3 for results of animal studies). The increased bleeding risk with Novastan may constitute a risk in treatment during pregnancy. Novastan contains ethanol. A 70 kg patient administered the maximum recommended daily dose (10 microgram/kg/min) would receive a dose of approximately 4 g ethanol per day.

Novastanshould be used during pregnancy only if treatment is clearly necessary.

Breast-feeding

Information concerning the passage of argatroban into humanmilkis not available. Animal studies using radiolabelled argatrobanhave shown that radioactivity reaches greater levels in breast milk than in maternal blood.A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from Novastan therapy taking into account the benefit of breast feeding for the child and the benefit of therapy for the woman.

Fertility

There are no data on potential effects of Novastan on fertility.

4.7 Effects on ability to drive and use machines

In theory, the presence of ethanol in the formulation (1 g per vial) may impair the patient’s ability to drive or operate machinery. However, this is unlikely to be of clinical relevance in patients receiving Novastan.

4.8 Undesirable effects

Bleeding complications, as is to be expected given the pharmacological properties, constitute the main adverse events. In the clinical trials involving patients with HIT type II anticoagulated with Novastan, the incidence of major bleeds was 31/568 (5.5%) and minor bleeds 221/568 (38.9%). The incidence of major bleeds was almost three times higher in those patients in whom the aPTT level exceeded more than three times the baseline value than in those whose aPTT was within the therapeutic range. Reports of cerebral haemorrhage have been received in association with use of argatroban. Their incidence has not been determined. Dosage of Novastan should be adjusted to achieve a target aPTT level of 1.5 to 3.0 times baseline not exceeding 100 seconds (see section 4.2).

The incidence of adverse reactions in clinical trials (568 patients with HIT Type II) which are considered to be possibly related to Novastan is stated below.

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 (see below)

<To be completed nationally>

4.9 Overdose

Excessive anticoagulation, with or without bleeding, may be controlled by discontinuing Novastan or by decreasing the infusion rate. In clinical studies, anticoagulation parameters return to baseline generally within 2 to 4 hours after discontinuation of Novastan. Reversal of anticoagulant effect may take longer in patients with hepatic impairment.

No specific antidote to Novastan is available. If life-threatening bleeding occurs and excessive plasma levels of argatroban are suspected, Novastan should be discontinued immediately and aPTT and other coagulation tests should be performed. Symptomatic and supportive therapy should be provided to the patient.

Lethal single intravenous doses of argatroban for mice, rats, rabbits, and dogs were 200, 124, 150, and 200 mg/kg respectively. The symptoms of acute toxicity were loss of righting reflex, tremors, clonic convulsions, paralysis of hind limbs, and coma.

Each vial contains 1 g ethanol.

5. PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Antithrombotic agents, direct thrombin inhibitors.

ATC code: B01AE03.

Argatroban, a synthetic L-arginine derivative, is a direct thrombin inhibitor (molecular weight of argatroban monohydrate is 526.65) that binds reversibly to thrombin. Argatroban exerts its anticoagulant effect independently of antithrombin III and inhibits fibrin formation; activation of coagulation factors V, VIII and XIII; activation of protein C; and platelet aggregation.

Argatroban is highly selective for thrombin; inhibitory constant (Ki) values in studies in vitro with synthetic tripeptides ranged from 5 to 39 nM.

Argatroban is capable of inhibiting the action of both free and clot-associated thrombin. It does not interact with heparin-induced antibodies. There was no evidence of formation of antibodies against argatroban in patients who received multiple doses of argatroban.

Evidence of the efficacy of Novastan in HIT type II derives from data from two studies where a total of 568 adult patients were treated with Novastan. The average treatment duration employed in these clinical studies was 6 days with a maximum of 14 days. In the first prospective trial, an improvement in the composite outcome at 37 days (death, amputation, new thrombosis) was observed in the Novastan group versus the historical controls (n=46). The reduction of the incidence of the primary endpoint was consistent in the subgroups of patients having HIT type II without thromboembolic complications (25.6% vs 38.8%), p=0.014 by categorical analysis; p=0.007 by time-to-event analysis) and HIT type II with thromboembolic complications (43.8% vs 56.5%, p=0.131 by categorical analysis; p=0.018 by time-to event analysis).

The studies were not statistically powered for individual endpoints. However, in the first prospective study, the reduction of the incidence of individual endpoints for patients having HIT type II without and with thromboembolic complications respectively was as follows: mortality (16.9 vs 21.8, n.s) and (18.1 vs 28.3%, n.s), amputation (1.9 vs 2.0%, n.s) and (11.1 vs 8.7%, n.s), new thromboses (6.9 vs 15%, p=0.027) and (14.6 vs 19.6%, n.s).

In the second follow-on study, similar outcomes were observed.

Paediatric population

The efficacy and safety of the use of Novastan in patients under 18 years of age has not been established. However, limited results from a prospective clinical study conducted in theUSA in 18 seriously ill paediatric patients with (suspected) HIT Type II requiring an alternative to heparin anticoagulation are available.

The age range of the patients participating in this study were less than six months (8 patients), six months to less than 8 years (6 patients) and 8 to 16 years (4 patients). All patients had serious underlying conditions and were receiving multiple concomitant medications.

Thirteen patients received Novastan solely as a continuous infusion (no bolus dose). In the majority of these 13 patients dosing was initiated at 1 microgram/kg/min to achieve an aPTT of 1.5 to 3 times the baseline value (not exceeding 100 seconds). Most patients required multiple dose adjustments to maintain anticoagulation parameters within the desired range.

During the 30 day study period thrombotic events occurred during Novastan administration in two patients and following Novastan discontinuation in three other patients. Major bleeding occurred among two patients; one patient experienced an intracranial haemorrhage after 4 days of Novastan therapy in the setting of sepsis and thromobocytopenia. Another patient completed 14 days of treatment but experienced an intracranial haemorrhage while receiving Novastan following completion of the study treatment period.

As only limited data is available, an initial continuous infusion rate of 0.75 microgram/kg/min has been suggested in seriously ill paediatric patients with normal hepatic function. Areduced starting dose of 0.2 microgram/kg/min would be suggested in seriously ill paediatric patients with impaired hepatic function (see Section 5.2).The dose adjusted to achieve target aPTT 1.5 to 3 times the baseline value, not exceeding 100 seconds.

5.2 Pharmacokinetic properties

Absorption

Steady-state levels of both argatroban and anticoagulant effect are typically attained within 1-3 hours and are maintained until the infusion is discontinued or the dosage adjusted. Steady-state plasma argatroban concentrations increase proportionally with dose (for infusion doses up to 40 microgram/kg/min in healthy subjects) and are well correlated with steady-state anticoagulant effects. For infusion doses up to 40 microgram/kg/min, argatroban increases, in a dose-dependent fashion, the activated partial thromboplastin time (aPTT), the activated clotting time (ACT), the International Normalized Ratio (INR) and the thrombin time (TT) in healthy volunteers and cardiac patients.

Distribution

Argatroban distributes mainly in the extra-cellular fluid. The volume of distribution (Vd) was 391 ± 155 ml/kg (mean ± SD). Argatroban is 54% bound in human serum proteins, with binding to albumin and ₁‑acid glycoprotein being 20% and 34% respectively.

Biotransformation

The metabolism of argatroban has not yet been fully characterized. The metabolites identified (M‑1, M‑2, and M‑3) are formed by hydroxylation and aromatization of the 3‑methyltetrahydroquinoline ring in the liver. The formation of the metabolites is catalysed in vitro by cytochrome P450 enzymes CYP3A4/5, but this is not a major path of elimination in vivo. The primary metabolite (M1) exerts 40-fold weaker antithrombin effect than argatroban. Metabolites M‑1, M‑2 and M‑3 were detected in the urine, and M-1 was detected in plasma and faeces.

There is no interconversion of the 21-(R) and 21-(S) diastereoisomers. The ratio of diastereoisomers is unchanged by metabolism or hepatic impairment, remaining constant at 65:35 (2%).

Elimination

On termination of the infusion, the concentration of argatroban decreased rapidly. The apparent terminal elimination half life (mean ± SD) is 52  16 min. Clearance (mean ± SD) was 5.2  1.3 ml/kg/min.

Argatroban is excreted mainly in the faeces, presumably through biliary secretion. Following intravenous infusion of ¹⁴C-radiolabelled argatroban 21.8 ± 5.8% of the dose was excreted in urine and 65.4 ± 7.1% in the faeces.

Special populations

Elderly: clearance is approximately 15% lower than in younger persons. No age related dose adjustment is necessary.

Renal impairment: compared with patients with normal renal function (creatinine clearance 80 ml/min) who had a terminal half-life of 4722 min, patients with severely impaired renal function (creatinine clearance 29 ml/min) had only slight prolongation of this value (6535 min). No initial dose regimen adjustment with respect to renal function is necessary.

Hepatic impairment: in patients with hepatic impairment (Child Pugh score 7 to 11) clearance was 26% of that of healthy volunteers. Initial dose reduction is required in patients with moderate hepatic impairment. Novastan is contraindicated in patients with severe hepatic impairment.

Paediatric patients: argatroban clearance is decreased in seriously ill paediatric patients. Based on population pharmacokineticmodeling, clearance in paediatric patients (0.17L/hr/kg) was 50% lower compared to healthy adults (0.31 L/hr/kg). Population pharmacokinetic data also indicate that the infusion rate should be adjusted according to body weight.

Other special populations:Based on population pharmacokineticmodeling, patients with elevated bilirubin (secondary to cardiac complications or hepatic impairment) had, on average, 80% lower clearance (0.03 L/hr/kg) when compared to paediatric patients with normal bilirubin levels.

5.3 Preclinical safety data

Preclinical data reveal no special hazard for humans based on conventional studies of safety pharmacology and genotoxicity.Toxicity studies with continuous intravenous infusionsand reproduction toxicity studies using daily intravenous bolus injections achieved only limited systemic exposure to argatroban (2 times the exposure seen in humans). Although these studies do notsuggestany particular risk to humans, their value is limited by the low systemic exposure realised.

6. PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Sorbitol (E 420i)

Anhydrous ethanol

Water for injections

6.2 Incompatibilities

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

6.3 Shelf‑life

Vial before opening

3 years. (see Section 6.4).

After dilution

Diluted solution: chemical and physical in-use stability has been demonstrated for up to 14 days at 25 ºC and 2 to 8 ºC in sodium chloride 9 mg/ml (0.9%) solution for infusion, glucose 50 mg/ml (5%) solution for infusion, or Sodium Lactate Intravenous Infusion Compound (see Section 6.6).

From a 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 not normally be longer than 24 hours at 2 to 8 ºC unless dilution has taken place in controlled and validated aseptic conditions.

6.4 Special precautions for storage

Vial before opening

Keep vial in the outer carton in order to protect from light.

Do not refrigerate or freeze.

After dilution

Diluted solutions should not be exposed to direct sunlight.

6.5 Nature and content of container

Clear 5 ml type I glass vial sealed with a fluoropolymer–coated chlorobutylrubber stopper and an aluminium crimp-seal with a polypropylene flip-off cap. Each vial contains 2.5 ml of concentrate for solution for infusion.

Vials are supplied in cardboard cartons of 1 or 6 vials. Not all pack-sizes may be marketed.

6.6 Special precautions for disposaland other handling

Novastan should be diluted in sodium chloride 9 mg/ml (0.9%) solution for infusion, glucose 50 mg/ml(5%)solution for infusion, or Sodium Lactate Intravenous Infusion Compound to a final concentration of 1 mg/ml. If the solution is cloudy, or if an insoluble precipitate is noted, the vial should be discarded.

Each 2.5 ml vial should be diluted 100-fold by mixing with 250 ml of diluent. The vial is for single use only. Use 250 mg (2.5 ml) per 250 ml of diluent or 500 mg (5 ml) per 500 ml of diluent. The constituted solution must be mixed by repeated inversion of the diluent bag or bottle for one minute. The diluted solution should be clear and practically free from visible particles. Upon preparation, the solution may show slight but brief haziness due to the formation of microprecipitates that rapidly dissolve upon mixing. The pH of the intravenous solution prepared as recommended is 3.2-7.5.

Light resisting measures such as foil protection for intravenous lines are not necessary. No significant potency losses have been noted following simulated delivery of the solution through intravenous tubing.

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

7. Marketing Authorisation Holder

MitsubishiTanabe Pharma Europe Ltd, Dashwood House, 69 Old Broad Street, London EC2M 1QS United Kingdom.

8. Marketing Authorisation Number(s)

19239

9. Date of First Authorisation/Renewal of the Authorisation

2004-10-15/2016-10-15

10. Date of Revision of the Text:

2016-09-29