Supply of energy and essential fatty acids and omega-3 fatty acids to patients, as part of a parenteral nutrition regimen, when oral or enteral nutrition is impossible, insufficient or contra-indicated.

Posology  

The patient’s ability to eliminate the fat infused, should govern the dosage and infusion rate, see section 4.4.

Adults  

The standard dose is 1.0 – 2.0 g fat/kg body weight (b.w.)/day, corresponding to 5 – 10 ml/kg b.w./day.

The recommended infusion rate is 0.125 g fat/kg b.w./hour, corresponding to 0.63 ml Smoflipid/kg b.w./hour, and should not exceed 0.15 g fat/kg b.w./hour, corresponding to 0.75 ml Smoflipid/kg b.w./hour.

Paediatric population
Neonates and infants

The initial dose should be 0.5 – 1.0 g fat/kg b.w./day followed by a successive increase by 0.5 – 1.0 g fat/kg b.w./day up to 3.0 g fat/kg b.w./day.

It is recommended not to exceed a daily dose of 3 g fat/kg b.w./d, corresponding to 15 ml Smoflipid/kg b.w./day.

The rate of infusion should not exceed 0.125 g fat/kg b.w./hour.

In premature and low birthweight neonates, Smoflipid should be infused continuously over about 24

hours.

Children

It is recommended not to exceed a daily dose of 3 g fat/kg b.w./d, corresponding to 15 ml Smoflipid/kg b.w./day.

The daily dose should be increased gradually during the first week of administration. The infusion rate should not exceed 0.15 g fat/kg b.w./hour.

Method of administration

Intravenous infusion into a peripheral or central vein.

When used in neonates and children below 2 years, the solution (in bags and administration sets) should be protected from light exposure until administration is completed (see section 4.4, 6.3 and 6.6).

- Hypersensitivity to fish-, egg-, soya- or peanut protein or to any of the active substances or excipients listed in section 6.1. - Severe hyperlipidemia. - Severe liver insufficiency. - Severe blood coagulation disorders. - Severe renal insufficiency without access to hemofiltration or dialysis. - Acute shock. - General contraindications to infusion therapy: acute pulmonary oedema, hyperhydration, decompensated cardiac insufficiency. - Unstable conditions (e.g. severe post-traumatic conditions, uncompensated diabetes mellitus, acute myocardial infarction, stroke, embolism, metabolic acidosis and severe sepsis and hypotonic dehydration).

The capacity to eliminate fat is individual and should therefore be monitored according to the routines of the clinician. This is in general done by checking the triglyceride levels. Special caution should be taken in patients with a marked risk for hyperlipidema (e.g. patients with high lipid dosage, severe sepsis and extremely low birth weight infants). The concentration of triglycerides in serum should in general not exceed 3 mmol/l during infusion. Reduction of the dosage or cessation of the lipid emulsion should be considered if serum or plasma triglyceride concentrations during or after infusion exceed 3 mmol/L. An overdose may lead to fat overload syndrome, see section 4.8.

This medicinal product contains soya-bean oil, fish oil and egg phospholipids, which may rarely cause allergic reactions. Cross allergic reaction has been observed between soya-bean and peanut.

Smoflipid should be given with caution in conditions of impaired lipid metabolism, which may occur in patients with renal failure, diabetes mellitus, pancreatitis, impaired liver function, hypothyroidism, and sepsis.

Clinical data in patients with diabetes mellitus or renal failure are limited.

Administration of medium-chain fatty acids alone can result in metabolic acidosis. This risk is to a great extent eliminated by the simultaneous infusion of the long chain fatty acids included in Smoflipid. Concomitant administration of carbohydrates will further eliminate this risk. Hence, simultaneous infusion of carbohydrate or a carbohydrate-containing amino acid solution is recommended. Laboratory test generally associated with monitoring of intravenous nutrition should be checked regularly. These include blood glucose levels, liver functions tests, acid base metabolism, fluid balance, full blood count and electrolytes.

Any sign or symptom of anaphylactic reaction (such as fever, shivering, rash or dyspnoea) should lead to immediate interruption of the infusion.

Smoflipid should be given with caution to neonates and premature neonates with hyperbilirubinemia and cases with pulmonary hypertension. In neonates, particularly premature neonates on long term parenteral nutrition, blood platelet counts, liver function tests and serum triglycerides should be monitored.

Light exposure of solutions for intravenous parenteral nutrition, especially after admixture with trace elements and/or vitamins, may have adverse effects on clinical outcome in neonates, due to generation of peroxides and other degradation products. When used in neonates and children below 2 years, Smoflipid should be protected from ambient light until administration is completed (see section 4.2, 6.3 and 6.6).

High levels of lipids in plasma may interfere with some laboratory blood tests, e.g. haemoglobin.

The addition of other medicaments or substances to Smoflipid should generally be avoided unless compatibility is known (see 6.2 and 6.6).

Parenteral Nutrition-Associated Liver Disease and Other Hepatobiliary Disorder

Parenteral nutrition-associated liver disease (PNALD), also referred to as intestinal failure associated liver disease (IFALD), can present as cholestasis or hepatic steatosis, and may progress to steatohepatitis with fibrosis and cirrhosis (possibly leading to chronic hepatic failure). The etiology of PNALD is multifactorial; however, intravenously administered phytosterols (plant sterols) contained in plant-derived lipid emulsions, including SMOFlipid, have been associated with development of PNALD. Monitor liver tests in patients treated with SMOFlipid and consider discontinuation or dosage reduction if abnormalities occur.

Hepatobiliary disorders including cholecystitis and cholelithiasis have developed in some PN-treated patient. Monitor liver tests when administering SMOFlipid. Patients developing signs of hepatobiliary disorders should be assessed early to determine whether these conditions are related to SMOFlipid use.

Death in Preterm Neonates

Deaths in preterm neonates after infusion of lipid injectable emulsions containing only soybean oil have been reported in the medical literature. Autopsy findings in these preterm neonates included intravascular lipid accumulation in the lungs. Preterm and small-for-gestational-age neonates have poor clearance of intravenous lipid emulsion and increased free fatty acid plasma levels following lipid emulsion infusion. This risk due to poor lipid clearance should be considered when administering intravenous lipid emulsions. Monitor patients receiving SMOFlipid for signs and symptoms of pleural or pericardial effusion.

Hypersensitivity Reactions

If a hypersensitivity reaction occurs, stop infusion of SMOFlipid immediately and initiate appropriate treatment and supportive measures.

Infections

Lipid emulsions, such as SMOFlipid, can support microbial growth and are an independent risk factor for the development of catheter-related bloodstream infections. To decrease the risk of infectious complications, ensure aseptic techniques are used for catheter placement, catheter maintenance, and preparation and administration of SMOFlipid. Monitor for signs and symptoms of infection including fever and chills, as well as laboratory test results that might indicate infection (including leukocytosis and hyperglycemia). Perform frequent checks of the intravenous catheter insertion site for edema, redness, and discharge.

 

Refeeding Syndrome

Administering PN to severely malnourished patients may result in refeeding syndrome, which is characterized by the intracellular shift of potassium, phosphorus, and magnesium as patients become anabolic. Thiamine deficiency and fluid retention may also develop. To prevent these complications, closely monitor severely malnourished patients and slowly increase their nutrient intake.

Hypertriglyceridemia

The use of SMOFlipid is contraindicated in patients with hypertriglyceridemia with serum triglyceride concentrations >1,000 mg/dL. 

Patients with conditions such as inherited lipid disorders, obesity, diabetes mellitus, or metabolic syndromes have a higher risk of developing hypertriglyceridemia with the use of SMOFlipid. In addition, patients with hypertriglyceridemia may have worsening of their hypertriglyceridemia with administration of SMOFlipid. Excessive dextrose administration may further increase such risk.

Evaluate patients’ capacity to metabolize and eliminate the infused lipid emulsion by measuring serum triglycerides before the start of infusion (baseline value) and regularly throughout treatment. If triglyceride levels are above 400 mg/dL in adults, stop the SMOFlipid infusion and monitor serum triglyceride levels to avoid clinical consequences of hypertriglyceridemia such as pancreatitis. In pediatric patients with hypertriglyceridemia, lower triglyceride levels (i.e., below 400 mg/dL) may be associated with adverse reactions. Monitor serum triglyceride levels to avoid potential complications with hypertriglyceridemia such as pancreatitis, lipid pneumonitis, and neurologic changes, including kernicterus.

To minimize the risk of new or worsening of hypertriglyceridemia, assess high-risk patients for their overall energy intake including other sources of lipids and dextrose, as well as concomitant drugs that may affect lipid and dextrose metabolism.

Aluminum Toxicity

SMOFlipid contains no more than 25 mcg/L of aluminum. Prolonged PN administration in patients with renal impairment may result in aluminum reaching toxic levels. Preterm neonates are at greater risk because their kidneys are immature and they require large amounts of calcium and phosphate solutions that contain aluminum. Patients with impaired kidney function, including preterm neonates, who receive parenteral levels of aluminum at greater than 4 to 5 mcg/kg/day can accumulate aluminum at levels associated with central nervous system and bone toxicity. Tissue loading in these patients may occur at even lower rates of administration.

Essential Fatty Acid Deficiency

Treatment-emergent cases of moderate or severe essential fatty acid deficiency (EFAD) (defined as the triene [Mead acid] to tetraene [arachidonic acid] ratio >0.2 and >0.4, respectively) were not observed in pediatric clinical trials of SMOFlipid up to 28 days. However, cases of EFAD have been reported in adult and pediatric patients in the postmarketing period with the use of SMOFlipid. The median time to onset was greater than 28 days among cases that reported time to onset.

Monitor patients for laboratory evidence (e.g., abnormal fatty acid levels) and clinical symptoms of EFAD (e.g., skin manifestations, poor growth). Laboratory testing using the triene to tetraene ratio may not be adequate to diagnose EFAD, and assessment of individual fatty acid levels may be needed. Ensure patients are receiving recommended dosages of SMOFlipid to prevent EFAD.

Monitoring/Laboratory Tests

Throughout treatment, monitor serum triglycerides [see 4.4 Special warnings and precautions for use], fluid and electrolyte status, blood glucose, liver and kidney function, coagulation parameters, and complete blood count including platelets.

The lipids contained in SMOFlipid may interfere with some laboratory blood tests (e.g., hemoglobin, lactate dehydrogenase, bilirubin, oxygen saturation) if blood is sampled before lipids have cleared from the bloodstream. Conduct these blood tests at least 6 hours after stopping the infusion.

Heparin given in clinical doses causes a transient increase in lipoprotein lipase release into the circulation. This may initially result in increased plasma lipolysis, followed by a transient decrease in triglyceride clearance.

Soybean and olive oils in SMOFlipid contain vitamin K1 which may counteract the anticoagulant activity of vitamin K antagonists such as warfarin. In patients who receive concomitant SMOFlipid and warfarin, increase monitoring of laboratory parameters for anticoagulant activity.

There are no data available on exposure of Smoflipid in pregnant or breast-feeding women. There are no studies available on reproductive toxicity in animals. Parenteral nutrition may become necessary during pregnancy and lactation. Available published literature includes fewer than five reported cases of breastfed infants exposed to various lipid emulsions via lactation, and these cases did not report adverse events. Smoflipid should only be given to pregnant and breast-feeding women after careful consideration.

Not relevant.

Undesirable effects observed during the administration of fat emulsions:

	Common (?1/100 to <1/10)	Uncommon (?1/1000 to <1/100)	Rare (?1/10,000 to <1/1000)	Very rare (<1/10,000)
Vascular disorders			Hypotension, hypertension
Respiratory, thoriacic and mediastinal disorders			Dyspnoea
Gastrointestinal disorders		Lack of appetite, nausea, vomiting
Reproductive system and breast disorders				Priapism

General disorders and administration site conditions	Slight increase in body temperature	Chills	Hypersensitivity- reactions (e.g. anaphylactic or anaphylactoid reactions, skin rash, urticaria, flush, headache), heat or cold sensation, paleness, cyanosis, pain in the neck, back, bones, chest and loins

 

Should these side-effects occur or should the triglyceride level during infusion rise above 3 mmol/l, the infusion of Smoflipid should be stopped or, if necessary, continued at a reduced dosage.

Smoflipid should always be a part of a complete parenteral nutritional treatment including amino acids and glucose. Nausea, vomiting and hyperglycemia are symptoms related to conditions indicating parenteral nutrition and may sometimes be associated with parenteral nutrition.

Monitoring of triglycerides and blood glucose levels are recommended to avoid elevated levels, which may be harmful.

Fat overload syndrome

Impaired capacity to eliminate triglycerides can lead to “Fat overload syndrome” which may be caused by overdose. Possible signs of metabolic overload must be observed. The cause may be genetic (individually different metabolism) or the fat metabolism may be affected by ongoing or previous illnesses.This syndrome may also appear during severe hypertriglyceridemia, even at the recommended infusion rate, and in association with a sudden change in the patient’s clinical condition, such as renal function impairment or infection. The fat overload syndrome is characterised by hyperlipemia, fever, fat infiltration, hepatomegaly with or without icterus, splenomegaly, anemia, leukopenia, thrombocytopenia, coagulation disorder, hemolysis and reticulocytosis, abnormal liver function tests and coma. The symptoms are usually reversible if the infusion of the fat emulsion is discontinued.

Should signs of a fat overload syndrome occur, the infusion of Smoflipid should be discontinued.

Post-marketing Experience

The following adverse reactions have been identified during post-approval use of SMOFlipid in countries where it is registered. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to product exposure.

 

Cardiac disorders: palpitations

General disorders and administration site conditions: chills, chest pain, malaise

Hepatobiliary disorders: cholestasis

Infections and infestations: infection

Metabolism and nutrition disorders: fatty acid deficiency Respiratory, thoracic and mediastinal disorders: dyspnea

Skin and subcutaneous tissue disorders: hyperhidrosis

Vascular disorders: phlebitis.

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.

·        Saudi Arabia:

·        The National Pharmacovigilance Centre (NPC): ·        SFDA Call Center: 19999 ·        E-mail: npc.drug@sfda.gov.sa Website: https://ade.sfda.gov.sa/ UAE:   -     Pharmacovigilance & Medical Device section: ·         P.O.Box: 1853 ·         Tel: 80011111 ·         E-mail: pv@mohap.gov.ae Drug Department Minisrty of Health & Prevention – Dubai- UAE Other GCC states: Please contact the relevant competent authority

Overdose leading to fat overload syndrome may occur as a result of a too rapid infusion rate, or chronically at recommended rates of infusion in association with a change in the patients clinical conditions e.g. renal function impairment or infection.

Overdosage may lead to side-effects (see section 4.8). In these cases the lipid infusion should be stopped or, if necessary, continued at a reduced dosage.

Pharmacotherapeutic group: Solutions for parenteral nutrition, fat emulsions
ATC-code: B05BA02

The fat emulsion has a particle size and biological properties similar to those of endogenous chylomicrons. The constituents of Smoflipid; soya-bean oil, medium-chain triglycerides, olive oil and fish oil have except for their energy contents, their own pharmacodynamic properties.

Soya-bean oil has a high content of essential fatty acids. The omega-6 fatty acid linoleic acid is the most abundant (approx. 55-60%). Alpha-linolenic acid, an omega-3 fatty acid, constitutes about 8 %. This part of Smoflipid provides the necessary amount of essential fatty acids.

Medium-chain fatty acids are rapidly oxidised and provide the body with a form of immediately available energy.

Olive oil mainly provides energy in the form of mono-unsaturated fatty acids, which are much less prone to peroxidation than the corresponding amount of poly-unsaturated fatty acids.

Fish oil is characterised by a high content of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). DHA is an important structural component of cell membranes, whereas EPA is a precursor of eicosanoids as prostaglandines, tromboxanes and leucotrienes.

Vitamin E protects unsaturated fatty acids against lipid peroxidation.

Two studies providing home parenteral nutrition in patients in need of long-term nutrition support have been performed. The primary objective in both studies was to show safety. Efficacy was the secondary objective in one of the studies, which was done in paediatric patients. This study was stratified by age groups (1 month - <2 years, and 2 – 11 years respectively). Both studies showed that Smoflipid has the same safety profile as the comparator (Intralipid 20%). Efficacy in the paediatric study was measured by weight gain, height, body mass index, pre-albumin, retinol binding protein and fatty acid profile. There was no difference between the groups in any of the parameters except the fatty acid profile after 4 weeks treatment. The fatty acid profile in the Smoflipid patients revealed an increase in omega-3 fatty acids in plasma lipoproteins and red blood cells phospholipids and hence reflects the composition of the infused lipid emulsion.

The individual triglycerides have different clearance rate but Smoflipid as a mixture is eliminated faster than long chain triglycerides (LCT) with lower triglyceride levels during infusion. Olive oil has the slowest clearance rate of the components (somewhat slower than LCT) and medium chain triglycerides (MCT) the fastest. Fish oil in a mixture with LCT has the same clearance rate as LCT alone.

In pre-clinical studies no other effects than those expected after high doses of lipids were observed, based on single dose and repeat dose toxicity and genotoxicity studies performed with the Smoflipid emulsion. In a local tolerance study in rabbits a slight, transient inflammation after intra-arterial, paravenous or subcutaneous administration was observed. After intra-muscular administration a moderate transient inflammation and tissue necrosis were seen in some animals.

In a test in guinea pigs (Maximisation test) fish oil showed moderate dermal sensitisation. A systemic antigenicity test gave no indication of evidence of anaphylactic potential of fish oil.

Glycerol

Egg lecithin

all-rac-a-Tocopherol

Water for injections

Sodium hydroxide for pH adjustment

Sodium oleate

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

2 years Shelf life after first opening the container Chemical and physical in-use stability has been demonstrated for 24 hours at 25°C. From a microbiological point of view the emulsion 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 2-8°C. When used in neonates and children below 2 years, the solution (in bags and administration sets) should be protected from light exposure until administration is completed (see section 4.2, 4.4 and 6.6).

Do not store above 25°C. Do not freeze.

Storage after mixing

If additions are made to Smoflipid, the admixtures should be used immediately from a microbiological point of view. If admixtures are 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 2-8°C, unless additions have taken place in controlled and validated aseptic conditions.

Glass bottles (type II, colourless) with stopper of butyl-rubber:

Excel bag. The excel bag consist of an inner bag (primary package) with an overpouch. An oxygen absorber and an integrity indicator (OxalertÔ) are placed between the inner bag and the overpouch.

-     The excel inner bag consists of a poly(propylene/ethylene) copolymer, a thermoplastic elastomer and a copolyester.

-     The oxygen barrier overpouch consists of polyethylene terephtalate and polyolefin or polyethylene terephtalate, polyolefin and ethylene-vinyl alcohol copolymer (EVOH).

-     The oxygen absorber consists of iron powder in a polymer sachet.

-     The integrity indicator consists of oxygen sensitive solution in a polymer sachet.

The overpouch, the oxygen absorber and the integrity indicator should be discarded after opening of the overpouch. The integrity indicator (OxalertÔ) will react with free oxygen and change colour from clear to black in case of damage in the overpouch.

Package sizes:

Glass bottle                         Excel bag

100 ml                                 100 ml

10x100 ml                           10x100 ml

250 ml                                 250 ml

10x250 ml                           10x250 ml

500 ml                                 500 ml

10x500 ml                           12x500 ml

Not all pack sizes may be marketed.

Use only if the emulsion is homogeneous.

When used in neonates and children below 2 years, protect from light exposure, until administration is completed. Exposure of Smoflipid to ambient light, especially after admixture with trace elements and/ or vitamins, generates peroxides and other degradation products that can be reduced by protection from light exposure (see section 4.2, 4.4 and 6.3).

For Infusionbag: The integrity indicator (Oxalert) should be inspected before removing the overpouch. If the indicator is black, oxygen has penetrated the overpouch and the product should be discarded.

Inspect the emulsion visually for phase separation prior to administration. Ensure that the final emulsion for infusion does not show any evidence of phase separation.

For single use only. Any unused emulsion should be discarded.

Additives  

Smoflipid may be aseptically admixed with amino acid, glucose, and electrolyte solutions to produce

"All-In-One" Total Parenteral Nutrition (TPN) admixtures.

Compatibility for different additives and the storage time of the different admixtures will be available upon request from the marketing authorisation holder.

Additions should be made aseptically.

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