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نشرة الممارس الصحي نشرة معلومات المريض بالعربية نشرة معلومات المريض بالانجليزية صور الدواء بيانات الدواء
  SFDA PIL (Patient Information Leaflet (PIL) are under review by Saudi Food and Drug Authority)

1. What Naropin is and what it is used for

 The name of your medicine is “Naropin solution for injection” or “Naropin solution for infusion”.

  • It contains a medicine called ropivacaine hydrochloride.
  •  It belongs to a group of medicines called local anaesthetics
  •  It will be given to you either as an injection or as an infusion, depending on what it is being used for.

Naropin 7.5 and 10 mg/ml is used in adults and children above 12 years of age to numb (anaesthetise) parts of the body. It is used to stop pain happening or to provide pain relief. It can be used to:

  • Numb parts of the body during surgery, including having a baby by Caesarean section.
  •  Relieve pain during childbirth, after surgery, or after an accident.

Naropin 2 mg/ml is used in adults and children of all ages for acute pain management. It numbs (anaesthetises) parts of the body e.g. after surgery.


2.What you need to know before you take Naropin

Do not take Naropin:

  • If you are allergic (hypersensitive) to ropivacaine hydrochloride or any of the other ingredients of Naropin (see Section 6: Further information).
  • If you are allergic to any other local anaesthetics of the same class (such as lidocaine or bupivacaine).
  • If you have been told that you have decreased volume of blood (hypovolaemia).
  • Into a blood vessel to numb a specific area of your body, or into the neck of the womb to relieve pain during childbirth.

If you are not sure if any of the above apply to you, talk to your doctor before you are given Naropin.

Warnings and precautions

Talk to your doctor or pharmacist before taking Naropin:

  •  if you have heart, liver or kidney problems. Your doctor may need to adjust the dose of Naropin.
  • if you have ever been told that you or anyone in your family has a rare disease of the blood pigment called "porphyria". Your doctor may need to give you a different anaesthetic medicine.
  • about any diseases or medical conditions that you have.

Special care should be given:

  •  in newborn children as they are more susceptible to Naropin.
  • in children up to and including 12 years as some injections to numb parts of the body are not established in younger children.
  •  in children up to and including 12 years as the use of Naropin 7.5 mg and 10 mg/ml injections to  numb parts of the body is not established. The strengths of Naropin 2mg/ml and 5 mg/ml may be more appropriate

 

Other medicines and Naropin

Tell your doctor if you are taking, have recently taken, or might take any other medicines. This includes medicines that you buy without a prescription and herbal medicines. This is because Naropin can affect the way some medicines work and some medicines can have an effect on Naropin.

In particular, tell your doctor if you are taking any of the following medicines:

  • Other local anaesthetics.
  • Strong pain killers, such as morphine or codeine.
  •  Drugs used to treat an uneven heart beat (arrhythmia), such as lidocaine and mexiletine.

Your doctor needs to know about these medicines to be able to work out the correct dose of Naropin for you. Also tell your doctor if you are taking any of the following medicines:

  • Medicines for depression (such as fluvoxamine)
  • Antibiotics to treat infections caused by bacteria (such as enoxacin).

This is because your body takes longer to get rid of Naropin if you are taking these medicines. If you are taking either of these medicines, prolonged use of Naropin should be avoided.

Pregnancy, breast-feeding and fertility

If you are pregnant or breast-feeding, think you may be pregnant or are planning to have a baby, ask your doctor for advice before you are given this medicine. It is not known if ropivacaine hydrochloride affects pregnancy or passes into breast milk.

Driving and using machines

Naropin may make you feel sleepy and affect the speed of your reactions. After you have been given Naropin, you should not drive or use tools or machines until the next day.

Naropin contains

up to 3.7 milligrams (mg) of sodium in each millilitre (ml) of solution. If you are on a sodium controlled diet you will need to take this into account.


3.How to take Naropin

Naropin will be given to you by a doctor. The dose that your doctor gives you will depend on the type of pain relief that you need. It will also depend on your body size, age, and physical condition.

Naropin will be given to you as an injection or as an infusion. The part of the body where it will be used will depend on why you are being given Naropin. Your doctor will give you Naropin in one of the following places:

  • The part of the body that needs to be numbed.
  • Near to the part of the body that needs to be numbed.
  •  In an area away from the part of the body that needs to be numbed. This is the case if you are given an epidural injection or infusion (into the area around the spinal cord).

When Naropin is used in one of these ways, it stops the nerves from being able to pass pain messages to the brain. It will stop you feeling pain, heat or cold in where it is used however you may still have other feelings like pressure or touch.

Your doctor will know the correct way to give you this medicine.

If you have been given too much Naropin

Serious side effects from getting too much Naropin need special treatment and the doctor treating you is trained to deal with these situations. The first signs of being given too much Naropin are usually as follows:

  •  Feeling dizzy or light-headed.
  • Numbness of the lips and around the mouth.
  • Numbness of the tongue.
  • Hearing problems.
  • Problems with your sight (vision).

To reduce the risk of serious side effects, your doctor will stop giving you Naropin as soon as these signs appear. This means that if any of these happen to you, or you think you have received too much Naropin, tell your doctor immediately.

More serious side effects from being given too much Naropin include problems with your speech, twitching of your muscles, tremors, trembling, fits (seizures), and loss of consciousness.


4.Possible side effects

Like all medicines, Naropin may cause side effects although not everybody gets them.

Important side effects to look out for:

Sudden life-threatening allergic reactions (such as anaphylaxis) are rare, affecting 1 to 10 users in 10,000. Possible symptoms include sudden onset of rash, itching or lumpy rash (hives); swelling of the face, lips, tongue or other parts of the body; and shortness of breath, wheezing or difficulty breathing. If you think that Naropin is causing an allergic reaction, tell your doctor immediately.

Other possible side effects:

Very common (affects more than 1 user in 10)

  •   Low blood pressure (hypotension). This might make you feel dizzy or light-headed.
  • Feeling sick (nausea).

Common (affects 1 to 10 users in 100)

  • Pins and needles.
  • Feeling dizzy.
  • Headache.
  • Slow or fast heart beat (bradycardia, tachycardia).
  •  High blood pressure (hypertension).
  • Being sick (vomiting).
  • Difficulty in passing urine.
  • High temperature (fever) or shivering (chills).
  • Back pain.

Uncommon (affects 1 to 10 users in 1,000)

  • Anxiety.
  • Decreased sensitivity or feeling in the skin.
  • Fainting.
  • Difficulty breathing.
  • Low body temperature (hypothermia).
  • Some symptoms can happen if the injection was given into a blood vessel by mistake, or if you have been given too much Naropin (see also “If you have been given too much Naropin” above). These include fits (seizures), feeling dizzy or light-headed, numbness of the lips and around the mouth, numbness of the tongue, hearing problems, problems with your sight (vision), problems with your speech, stiff muscles, and trembling.

Rare (affects 1 to 10 users in 10,000)

  • Heart attack (cardiac arrest).
  • Uneven heart beat (arrhythmias).

Other possible side effects include:

  •  Numbness, due to nerve irritation caused by the needle or the injection. This does not usually last for long.
  •  Involuntary muscle movements (dyskinesia).

Possible side effects seen with other local anaesthetics which might also be caused by Naropin include:

  • Damaged nerves. Rarely (affecting 1 to 10 users in 10,000), this may cause permanent problems.
  • If too much Naropin is given into the spinal fluid, the whole body may become numbed (anaesthetised).

Additional side effects in children

In children, the side effects are the same as in adults except for low blood pressure which happens less often in children (affecting 1 to 10 children in 100) and being sick which happens more often in children (affecting more than 1 in 10 children).


5. How to store Naropin

  •  Keep out of the sight and reach of children.
  • Do not use this medicine after the expiry date which is stated on the carton after EXP. The expiry date refers to the last day of that month.
  •  Do not store above 30°C. Do not freeze.
  •  Your doctor or the hospital will normally store Naropin and they are responsible for the quality of the product when it has been opened if it is not used immediately. The medicinal product should be visually inspected prior to use. The solution should only be used if it is clear, practically free from particles and if the container is undamaged.
  • They are also responsible for disposing of any unused Naropin correctly.

a.What Naropin contains

The active ingredient is ropivacaine hydrochloride. Naropin comes in the following strengths: 2 mg, 7.5 mg or 10 mg of ropivacaine hydrochloride per ml of solution.

The other ingredients are sodium chloride, hydrochloric acid and/or sodium hydroxide, and water for injections.


b.What Naropin looks like and contents of the pack Naropin is a clear, colourless solution for injection or infusion. Naropin solution for injection 2 mg/ml, 7.5 mg/ml and 10 mg/ml is available as follows: • 10 ml polypropylene ampoules (Polyamp) in packs of 5 or 10. • 20 ml polypropylene ampoules (Polyamp) in packs of 5 or 10. Naropin solution for infusion 2 mg/ml is available as follows: • 100 ml polypropylene bags (Polybag) in packs of 5. • 200 ml polypropylene bags (Polybag) in packs of 5. Not all pack sizes may be marketed.

c.   Marketing Authorisation Holder and Manufacturer

The Marketing Authorisations for Naropin are held by

Aspen Pharma Trading Limited 3016 Lake Drive

Citywest Business Campus Dublin 24

Ireland

The manufacturer responsible for batch release is

AstraZeneca AB

S-151 85 Södertälje Sweden

And

AstraZeneca UK Limited Silk Road Business Park Macclesfield

Cheshire SK10 2NA

United Kingdom


d. This leaflet was last approved in {September/2018}; version number {001}
  نشرة الدواء تحت مراجعة الهيئة العامة للغذاء والدواء (اقرأ هذه النشرة بعناية قبل البدء في استخدام هذا المنتج لأنه يحتوي على معلومات مهمة لك)

1. ما هو ناروبين وما هي دواعي استخدامه

اسم الدواء "ناروبين محلول للحقن" أو "ناروبين محلول للحقن الوريدي".

  • يحتوي على دواء يُسمى هيدروكلوريد الروبيفاكايين.
  • وهو ينتمي إلى مجموعة من الأدوية يطلق عليها أدوية التخدير الموضعي.
  • ويتلقاه المريض إما عن طريق الحقن أو الحقن الوريدي، وذلك بحسب الغرض الذي يستخدم من أجله.

يُستخدم ناروبين 7.5 و10 ملغ/مل في البالغين والأطفال أكبر من 12 عاماً لتخدير (تنميل) أجزاء من الجسم. ويستخدم في إيقاف ألم حالي أو لتسكين الألم. يمكن استخدامه في الأغراض التالية:

  • تخدير أجزاء من الجسم أثناء إجراء الجراحات، بما في ذلك الولادة بالعملية القيصرية.
  • تسكين الآلام أثناء الولادة، وبعد الجراحة، أو بعد التعرض لحادثة.

يستخدم ناروبين 2 ملغ/مل في البالغين والأطفال من جميع الأعمار لإدارة الآلام الحادة. يقوم بتخدير (تنميل) أجزاء من الجسم، على سبيل المثال بعد الخضوع للجراحات.

2. ما الذي يجب أن تعرفه قبل استخدام ناروبين

لا تستخدم ناروبين:

  • إذا كنت مصاباً بحساسية (حساسية مفرطة) لمادة هيدروكلوريد الروبيفاكايين أو لأي من مكونات ناروبين الأخرى (انظر القسم 6: معلومات أخرى).
  • إذا كنت حساساً لأي من أدوية التخدير الموضعي الأخرى من الفئة نفسها (مثل ليدوكايين أو بوبيفاكايين).
  • إذا تم إخبارك من قبل بانخفاض حجم الدم لديك (نقص حجم الدم).
  • في وعاء دموي لتخدير منطقة محددة من الجسم، أو في عنق الرحم لتسكين الألم أثناء الولادة.

إن لم تكن متأكداً أن أياً مما ورد أعلاه ينطبق عليك، تحدث مع طبيبك قبل تلقي ناروبين.

التحذيرات والاحتياطات

تحدث مع طبيبك أو الصيدلي قبل استخدام ناروبين:

  • إذا كانت لديك مشاكل قلبية، أو كبدية، أو كلوية. فقد يحتاج طبيبك إلى تعديل جرعة ناروبين.
  • إذا تم إخبارك من قبل أنك أو أي فرد في عائلتك مصاب بمرض نادر في الصباغ الدموي يُسمى "البُرْفيرِيَّة". قد يحتاج طبيبك إلى إعطائك دواء تخديري مختلف.
  • حول أي مرض أو حالة صحية لديك.

يجب توخي الحذر:

  • مع الأطفال حديثي الولادة حيث أنهم أكثر عرضة لمخاطر ناروبين.
  • في الأطفال 12 عاماً وأقل حيث أنه لم يثبت مدى فعالية وأمان بعض الحقن لتخدير أجزاء من الجسم في الأطفال الصغار.
  • في الأطفال 12 عاماً وأقل حيث أنه لم يثبت مدى فعالية وأمان استخدام ناروبين 7.5 ملغ و10 ملغ/مل لتخدير أجزاء من الجسم. قد يكون تركيزا ناروبين 2 ملغ/مل و5 ملغ/مل مناسبين أكثر.

الأدوية الأخرى وناروبين

أخبر طبيبك إن كنت تتناول أو تناولت مؤخراً أو قد تتناول أي أدوية أخرى. وهذا يشمل الأدوية التي يمكن شراؤها دون وصفة طبية والأدوية العشبية. هذا لأن ناروبين قد يؤثر على طريقة عمل بعض الأدوية وقد تؤثر بعض الأدوية على عمل ناروبين.

أخبر طبيبك إن كنت تتناول أي من الأدوية التالية على وجه الخصوص:

  • أدوية التخدير الموضعي الأخرى.
  • مسكنات ألم قوية، مثل المورفين أو الكوديين.
  • الأدوية التي تُستخدم في علاج عدم انتظام ضربات القلب (اضطراب النظم القلبي) مثل ليدوكايين، أو ميكسيليتين.

يحتاج طبيبك إلى معرفة إذا ما كنت تتناول هذه الأدوية ليتمكن من تحديد الجرعة المناسبة لك من ناروبين.

أخبر أيضاً طبيبك إذا كنت تتناول أياً من الأدوية التالية:

  • أدوية للاكتئاب (مثل فلوفوكسامين)
  • مضادات حيوية لعلاج الالتهابات بسبب البكتريا (مثل إنوكساسين).

وهذا لأن الجسم يستغرق وقتاً طويلاً لطرح ناروبين إذا كنت تتناول هذه الأدوية. إذا كنت تتناول أياً من هذه الأدوية، يجب تجنب الاستخدام المطول لناروبين.

الحمل والرضاعة الطبيعية والخصوبة

إذا كنتِ حاملاً أو ترضعين رضاعة طبيعية، أو تعتقدين أنكِ قد تكونين حاملاً أو تخططين للحمل، اطلبي المشورة من طبيبك قبل تلقي هذا الدواء. من غير المعروف إذا هيدروكلوريد الروبيفاكايين يؤثر على الحمل أو يُفرز في حليب الثدي.

القيادة واستخدام الآلات

قد يتسبب ناروبين في إشعارك بالنعاس ويؤثر على سرعة ردود فعلك. بعد تلقي ناروبين، يجب عليك الامتناع عن القيادة أو استخدام الأدوات والآلات إلى اليوم التالي.

يحتوي ناروبين

بحد أقصى 3.7 ملليغرام (ملغ) من الصوديوم في كل ملليلتر (مل) من المحلول. إذا كنت تتبع نظاماً غذائياً قليل الصوديوم، ستحتاج إلى أخذ ذلك في الاعتبار.

https://localhost:44358/Dashboard

3. كيفية استخدام ناروبين

سيقوم طبيبك بإعطائك ناروبين. تُحدد الجرعة التي يعطيها لك الطبيب بحسب نوع تسكين الألم الذي تحتاجه. وأيضاً بحسب حجم الجسم، والسن، والحالة الصحية.

سيُقدم لك ناروبين إما عن طريق الحقن أو الحقن الوريدي. يُحدد الجزء من الجسم التي سيُحقن بحسب السبب الذي تتلقى ناروبين من أجله. سيعطيك الطبيب ناروبين في إحدى المواضع التالية:

  • الجزء من الجسم الذي يلزم تخديره.
  • قرب الجزء من الجسم الذي يلزم تخديره.
  • في مكان بعيد عن الجزء من الجسم الذي يلزم تخديره. وهذا هو الحال عندما تتلقى حقناً فوق الجافية أو حقناً وريدياً (في المنطقة حول الحبل الشوكي).

عند استخدام ناروبين بإحدى هذه الطرق، فإنه يوقف قدرة الأعصاب على تمرير رسائل الألم إلى الدماغ. سيوقف الإحساس بالألم، أو السخونة، أو البرودة في الموضع الذي يُستخدم به، إلا إنك قد تشعر بأحاسيس أخرى مثل الضغط أو اللمس.

يعرف الطبيب الطريقة الصحيحة لإعطائك هذا الدواء.

إذا تلقيت جرعة أكبر مما ينبغي من ناروبين

تتطلب الآثار الجانبية الخطيرة الناتجة عن استخدام جرعة أكبر مما ينبغي من ناروبين علاجاً خاصاً، والطبيب الذي يعالجك مدرب على التعامل مع هذه المواقف. عادة ما تكون العلامات الأولى على تلقي جرعة أكبر من اللازم من ناروبين على النحو التالي:

  • شعور بالدوّار أو الدوخة.
  • تنميل في الشفتين وحول الفم.
  • تنميل في اللسان.
  • مشاكل سمعية.
  • مشاكل إبصارية (في الرؤية).

للحد من مخاطر الآثار الجانبية الخطيرة، يتوقف الطبيب عن إعطائك ناروبين بمجرد ظهور هذه العلامات. يعني ذلك أنه في حالة ظهور أي من هذه العلامات عليك، أو تظن أنك تلقيت جرعة أكبر من اللازم من ناروبين، يجب أن تخبر طبيبك على الفور.

الآثار الجانبية الأشد خطورة من تلقي جرعة أكبر من اللازم من ناروبين تتضمن صعوبة التحدث، ونفضان في العضلات، ورعشة، وارتجاف، ونوبات (تشنجات)، وفقدان الوعي.

4. الآثار الجانبية المحتملة

مثل جميع الأدوية، يمكن أن يسبب ناروبين آثاراً جانبية، على الرغم من أنه ليس بالضرورة أن يعاني منها الجميع.

آثار جانبية هامة يجب الانتباه لها:

ردود الفعل التحسسية المفاجئة المهددة للحياة (مثل التأق) نادرة، تؤثر على 1 إلى 10 مستخدمين في 10000. تتضمن الأعراض المحتملة ظهور مفاجئ لطفح جلدي أو حكة أو طفح جلدي مصحوب بكتل (شرى)، تورم الوجه، أو الشفتين، أو اللسان، أو أجزاء أخرى من الجسم، وضيق التنفس، أو صفير، أو صعوبة في التنفس. إذا كنت تظن أن ناروبين يثير رد فعل تحسسي، أخبر طبيبك على الفور.

الآثار الجانبية الأخرى المحتملة:

شائعة جداً (تؤثر على أكثر من 1 من كل 10 مستخدمين)

  • انخفاض ضغط الدم (هبوط ضغط الدم). قد يشعرك ذلك بالدوّار أو الدوخة.
  • رغبة في القيء (الغثيان).

أعراض جانبية شائعة (تؤثر على 1 إلى 10 مستخدمين من كل 100 مستخدم)

  • وخز دبابيس وإبر.
  • شعور بالدوّار.
  • صداع.
  • تباطؤ أو تسارع ضربات القلب (بطء القلب، تسرع القلب).
  • ارتفاع ضغط الدم.
  • قيء.
  • صعوبة في التبول.
  • ارتفاع درجة الحرارة (حمى)، ارتعاد (رعشة).
  • ألم بالظهر.

غير شائعة (تؤثر على 1 إلى 10 مستخدمين من كل 1000 مستخدم)

  • قلق.
  • انخفاض التحسس أو الشعور بالجلد.
  • إغماء.
  • صعوبة التنفس.
  • انخفاض درجة حرارة الجسم (هبوط حرارة الجسم)
  • قد تظهر بعض الأعراض إذا تلقيت الحقنة في وعاء دموي بالخطأ، أو إذا تلقيت جرعة أكبر من اللازم من ناروبين (انظر أيضاً "إذا تلقيت جرعة أكبر مما ينبغي من ناروبين" أعلاه). تتضمن هذه الاعراض نوبات (تشنجات)، والشعور بالدوخة أو الدوّار، وتنميل في الشفتين وحول الفم، وتنميل في اللسان، ومشاكل سمعية، ومشاكل إبصارية (الرؤية)، وصعوبة التحدث، وتصلب العضلات، ورجفة.

نادرة (تؤثر على 1 إلى 10 مستخدمين من كل 10000 مستخدم)

  • أزمة قلبية (سكتة قلبية).
  • عدم انتظام ضربات القلب (اضطراب النظم القلبي).

الآثار الجانبية الأخرى المحتملة:

  • تنميل، بسبب التهيج العصبي الذي تتسبب به الإبرة أو الحقن. عادة لا يستمر ذلك طويلاً.
  • حركات لا إرادية بالعضلات (خلل الحركة).

الآثار الجانبية المحتملة التي لوحظت مع أدوية التخدير الموضعي الأخرى التي قد يتسبب بها أيضاً ناروبين تتضمن:

  • تلف الأعصاب. نادرة (تؤثر على 1 إلى 10 مستخدمين في كل 10000 مستخدم)، قد تتسبب في مشاكل دائمة.
  • في حالة تلقي جرعة أكبر مما ينبغي من ناروبين في السائل الشوكي، قد يتخدر الجسم بأكمله.

آثار جانبية إضافية عند الاطفال

عند الأطفال، الآثار الجانبية هي نفسها التي تظهر على البالغين فيما عدا انخفاض ضغط الدم الذي يحدث بوتيرة أقل عند الأطفال (حيث يؤثر على 1 إلى 10 أطفال في كل 100 طفل) والقئ الذي يحدث بوتيرة أعلى في الأطفال (بحيث يؤثر على أكثر من 1 في كل 10 أطفال).

5. كيفية تخزين ناروبين

  • يُحفظ بعيداً عن مرأى ومتناول الأطفال.
  • لا تستخدم هذا الدواء بعد تاريخ انتهاء الصلاحية الموضح على العلبة الكرتونية الخارجية بعد عبارة "تاريخ انتهاء الصلاحية" (EXP). يشير تاريخ انتهاء الصلاحية إلى آخر يوم من ذلك الشهر.
  • لا يُخزن في درجة حرارة أعلى من 30 درجة مئوية. لا تجمد هذا الدواء.
  • عادةً الطبيب أو المستشفى هما من يقوم بتخزين ناروبين وهما المسؤولان عن جودة المستحضر عند فتحه إن لم يُستخدم على الفور. يجب فحص هذا المستحضر الدوائي خارجياً قبل استخدامه. يجب استخدام المحلول فقط إذا كان صافياً، وتقريباً خالياً من الجزيئات والحاوية سليمة.
  • وهما أيضاً المسؤولان عن التخلص من أي عبوات غير مستعملة من ناروبين بالشكل الصحيح.

أ-محتويات ناروبين

المادة الفعالة هي هيدروكلوريد الروبيفاكايين. يورد ناروبين بالتركيزات التالية: 2 ملغ أو 7.5 ملغ أو 10 ملغ من هيدروكلوريد الروبيفاكايين في كل مل من المحلول.

المكونات الأخرى هي كلوريد الصوديوم، حمض الهيدروكلوريك و/أو هيدروكسيد الصوديوم، وماء للحقن.

ب-كيف يبدو ناروبين وما هي محتويات العبوة

ناروبين محلول للحقن أو الحقن الوريدي صافٍ، عديم اللون.

ناروبين محلول للحقن 2 ملغ/مل، 7.5 ملغ/مل، و10 ملغ/مل متوفر على النحو التالي:

  • عبوات تحتوي على 5 أو 10 أمبولات بولي بروبيلين 10 مل (بوليامب).
  • عبوات تحتوي على 5 أو 10 أمبولات بولي بروبيلين 20 مل (بوليامب).

ناروبين محلول للحقن الوريدي 2 ملغ/مل متوفر على النحو التالي:

  • عبوات تحتوي على 5 عبوات بولي بروبيلين 100 مل (بوليباج).
  • عبوات تحتوي على 5 عبوات بولي بروبيلين 200 مل (بوليباج).

قد لا تكون جميع أحجام العبوات مسوقة في بلدك.

ت-مالك حق التسويق والمُصَّنع

مالك التراخيص التسويقية لناروبين

أسبن فارما تريدينغ المحدودة
3016 ليك درايف
مجمع سيتي ويست للأعمال
دبلن 24،
أيرلندا

الشركة المصنعة المسؤولة عن الدفعة المنتجة:

أسترازينيكا ايه بي
إس - 151 85 سودرتاليا
السويد

و

أسترازينيكا المملكة المتحدة المحدودة،
مجمع الأعمال سيلك رود
ماكليسفيلد
تشيشير
إس كي10 2 إن ايه
المملكة المتحدة

ث- تم الموافقة على هذه النشرة بتاريخ {سبتمبر / 2018} ، {001}
 Read this leaflet carefully before you start using this product as it contains important information for you

Naropin 2 mg/ml solution for injection

1 ml solution for injection contains ropivacaine hydrochloride monohydrate equivalent to 2 mg ropivacaine hydrochloride. 1 ampoule of 10 ml or 20 ml solution for injection contains ropivacaine hydrochloride monohydrate equivalent to 20 mg and 40 mg ropivacaine hydrochloride respectively. Excipients with known effect: Each 10 ml ampoule contains 1.48 mmol (34 mg) sodium. Each 20 ml ampoule contains 2.96 mmol (68 mg) sodium. For the full list of excipients, see section 6.1.

Solution for injection. Clear, colourless solution.

Naropin 7.5 mg/ml is indicated in adults and adolescents aged above 12 years of age for: Surgical anaesthesia:

-  Epidural blocks for surgery, including Caesarean section.

-  Major nerve blocks.

-  Field blocks.

Naropin 10 mg/ml is indicated in adults and adolescents aged above 12 years of age for: Surgical anaesthesia:

-  Epidural blocks for surgery.

Naropin 2 mg/ml is indicated for acute pain management

In adults and adolescents above 12 years of age for:

-  Continuous epidural infusion or intermittent bolus administration during postoperative or labour pain.

-  Field blocks.

- Continuous peripheral nerve block via a continuous infusion or intermittent bolus injections, e.g. postoperative pain management.

In infants from 1 year and children up to and including 12 years of age (per- and postoperative):

-  Single and continuous peripheral nerve block.

In neonates, infants and children up to and including 12 years of age for (per- and postoperative):

-  Caudal epidural block.

-  Continuous epidural infusion.


Naropin should only be used by, or under the supervision of, clinicians experienced in regional anaesthesia.

Posology

Adults and adolescents above 12 years of age:

The following table is a guide to dosage for the more commonly used blocks. The smallest dose required to produce an effective block should be used. The clinician's experience and knowledge of the patient's physical status are of importance when deciding the dose.

Table 1 Adults and adolescents above 12 years of age

 

Conc.

Volume

Dose

Onset

Duration

mg/ml

ml

mg

minutes

hours

SURGICAL ANAESTHESIA

Lumbar Epidural Administration

Surgery

7.5

15–25

113–188

10–20

3–5

10.0

15–20

150–200

10–20

4–6

Caesarean section

7.5

15–20

113–150(1)

10–20

3–5

Thoracic Epidural Administration

To establish block for postoperative pain relief

7.5

5–15

(dependent on the level of injection)

38–113

10–20

n/a(2)

Major Nerve Block*

Brachial plexus block

7.5

30–40

225–300(3)

10–25

6–10

Field Block

(e.g. minor nerve blocks and infiltration)

7.5

1–30

7.5–225

1–15

2–6

ACUTE PAIN MANAGEMENT

Lumbar Epidural Administration

Bolus

2.0

10–20

20–40

10–15

0.5–1.5

Intermittent injections (top up) (e.g. labour pain management)

2.0

10–15

(minimum interval 30 minutes)

20–30

 

 

Continuous infusion e.g. labour pain

2.0

6–10 ml/h

12–20 mg/h

n/a(2)

n/a(2)

Postoperative pain management

2.0

6–14 ml/h

12–28 mg/h

n/a(2)

n/a(2)

Thoracic Epidural Administration

Continuous infusion (postoperative pain management)

2.0

6–14 ml/h

12–28 mg/h

n/a(2)

n/a(2)

Field Block

(e.g. minor nerve blocks and infiltration)

2.0

1–100

2–200

1–5

2–6

Peripheral nerve block (Femoral or interscalene block)

Continuous infusion or intermittent injections

(e.g. postoperative pain management)

2.0

5–10 ml/h

10–20 mg/h

n/a

n/a

The doses in the table are those considered to be necessary to produce a successful block and should be regarded as guidelines for use in adults. Individual variations in onset and duration occur. The figures in the column 'Dose' reflect the expected average dose range needed. Standard textbooks should be consulted for both factors affecting specific block techniques and individual patient requirements.

* With regard to major nerve block, only for brachial plexus block a dose recommendation can be given. For other major nerve blocks lower doses may be required. However, there is presently no experience of specific dose recommendations for other blocks.

(1)   Incremental dosing should be applied, the starting dose of about 100 mg (97.5 mg = 13 ml; 105 mg = 14 ml) to be given over 3–5 minutes. Two extra doses, in total an additional 50mg, may be administered as needed.

(2)   n/a = not applicable.

The dose for a major nerve block must be adjusted according to site of administration and patient status. Interscalene and supraclavicular brachial plexus blocks may be associated with a higher frequency of serious adverse reactions, regardless of the local anaesthetic used, (see section 4.4).

In general, surgical anaesthesia (e.g. epidural administration) requires the use of the higher concentrations and doses. The Naropin 10 mg/ml formulation is recommended for epidural anaesthesia in which a complete motor block is essential for the surgery. For analgesia (e.g. epidural administration for acute pain management) the lower concentrations and doses are recommended.

Method of administration

Careful aspiration before and during injection is recommended to prevent intravascular injection. When a large dose is to be injected, a test dose of 3–5 ml lidocaine (lignocaine) with adrenaline (epinephrine) is recommended. An inadvertent intravascular injection may be recognised by a temporary increase in heart rate and an accidental intrathecal injection by signs of a spinal block.

Aspiration should be performed prior to and during administration of the main dose, which should be injected slowly or in incremental doses, at a rate of 25–50 mg/min, while closely observing the patient's vital functions and maintaining verbal contact. If toxic symptoms occur, the injection should be stopped immediately.

In epidural block for surgery, single doses of up to 250 mg ropivacaine have been used and well tolerated.

In brachial plexus block a single dose of 300 mg has been used in a limited number of patients and was well tolerated.

When prolonged blocks are used, either through continuous infusion or through repeated bolus administration, the risks of reaching a toxic plasma concentration or inducing local neural injury must be considered.

Cumulative doses up to 675 mg ropivacaine for surgery and postoperative analgesia administered over 24 hours were well tolerated in adults, as were postoperative continuous epidural infusions at rates up to 28 mg/hour for 72 hours. In a limited number of patients, higher doses of up to 800 mg/day have been administered with relatively few adverse reactions.

For treatment of postoperative pain, the following technique can be recommended: Unless preoperatively instituted, an epidural block with Naropin 7.5 mg/ml is induced via an epidural catheter. Analgesia is maintained with Naropin 2 mg/ml infusion. Infusion rates of 6–14 ml (12–28 mg) per hour provide adequate analgesia with only slight and non-progressive motor block in most cases of moderate to severe postoperative pain. The maximum duration of epidural block is 3 days. However, close monitoring of analgesic effect should be performed in order to remove the catheter as soon as the pain condition allows it. With this technique a significant reduction in the need for opioids has been observed.

In clinical studies an epidural infusion of Naropin 2 mg/ml alone or mixed with fentanyl 1-4 μg/ml has been given for postoperative pain management for up to 72 hours. The combination of Naropin and fentanyl provided improved pain relief but caused opioid side effects. The combination of Naropin and fentanyl has been investigated only for Naropin 2 mg/ml.

When prolonged peripheral nerve blocks are applied, either through continuous infusion or through repeated injections, the risks of reaching a toxic plasma concentration or inducing local neural injury must be considered. In clinical studies, femoral nerve block was established with 300 mg Naropin 7.5 mg/ml and interscalene block with 225 mg Naropin 7.5 mg/ml, respectively, before surgery. Analgesia was then maintained with Naropin 2 mg/ml. Infusion rates or intermittent injections of 10–20 mg per hour for 48 hours provided adequate analgesia and were well tolerated.

Concentrations above 7.5 mg/ml Naropin have not been documented for Caesarean section.

Paediatric population

Table 2 Epidural Block: Paediatric patients 0 (term neonates) up to and including 12 years of age

 

Conc.

Volume

Dose

mg/ml

ml/kg

mg/kg

ACUTE PAIN MANAGEMENT

(per- and postoperative)

Single Caudal Epidural Block

Blocks below T12, in children with a body weight up to 25 kg

2.0

1

2

Continuous Epidural Infusion

In children with a body weight up to 25 kg

 

 

 

0 up to 6 months

Bolus dosea

Infusion up to 72 hours

2.0

2.0

0.5–1

0.1 ml/kg/h

1–2

0.2 mg/kg/h

6 up to 12 months

Bolus dosea

Infusion up to 72 hours

2.0

2.0

0.5–1

0.2 ml/kg/h

1–2

0.4 mg/kg/h

1 to 12 years

Bolus doseb

Infusion up to 72 hours

2.0

2.0

1

0.2 ml/kg/h

2

0.4 mg/kg/h

The dose in the table should be regarded as guidelines for use in paediatrics. Individual variations occur. In children with a high body weight, a gradual reduction of the dosage is often necessary and should be based on the ideal body weight. The volume for single caudal epidural block and the volume for epidural bolus doses should not exceed 25 ml in any patient. Standard textbooks should be consulted for factors affecting specific block techniques and for individual patient requirements.

a Doses in the low end of the dose interval are recommended for thoracic epidural blocks while doses in the high end are recommended for lumbar or caudal epidural blocks.

b Recommended for lumbar epidural blocks. It is good practice to reduce the bolus dose for thoracic epidural analgesia.

The use of ropivacaine 7.5 and 10 mg/ml may be associated with systemic and central toxic events in children. Lower strength (2 mg/ml) is more appropriate for administration in this population.

The use of ropivacaine in premature children has not been documented.

Table 3 Peripheral nerve blocks: Infants and children aged 1-12 years

 

Conc.

Volume

Dose

mg/ml

ml/kg

mg/kg

ACUTE PAIN MANAGEMENT

 

 

 

(per- and postoperative)

 

 

 

Single injections for peripheral nerve block

e.g. ilioinguinal nerve block, brachial plexus block, fascia iliaca compartment block

2.0

0.5-0.75

1.0-1.5

Multiple blocks

2.0

0.5-1.5

1.0-3.0

Continuous infusion for peripheral nerve block in children 1 to 12 years. Infusion up to 72 hours

2.0

0.1-0.3 ml/kg/h

0.2-0.6 mg/kg/h

The dose in the table should be regarded as guidelines for use in paediatrics. Individual variations occur. In children with a high body weight a gradual reduction of the dosage is often necessary and should be based on the ideal body weight. Standard textbooks should be consulted for factors affecting specific block techniques and for individual patient requirements.

Single injections for peripheral nerve block (e.g. ilioinguinal nerve block, brachial plexus block, fascia iliaca compartment block) should not exceed 2.5-3.0 mg/kg.

The doses for peripheral block in infants and children provide guidance for use in children without severe disease. More conservative doses and close monitoring are recommended for children with severe diseases.

Method of administration

Careful aspiration before and during injection is recommended to prevent intravascular injection. The patient's vital functions should be observed closely during the injection. If toxic symptoms occur, the injection should be stopped immediately.

A single caudal epidural injection of ropivacaine 2 mg/ml produces adequate postoperative analgesia below T12 in the majority of patients when a dose of 2 mg/kg is used in a volume of 1 ml/kg. The volume of the caudal epidural injection may be adjusted to achieve a different distribution of sensory block, as recommended in standard textbooks. In children above 4 years of age, doses up to 3 mg/kg of a concentration of ropivacaine 3 mg/ml have been studied. However, this concentration is associated with a higher incidence of motor block.

Fractionation of the calculated local anaesthetic dose is recommended, whatever route of administration.


Hypersensitivity to ropivacaine or to other local anaesthetics of the amide type. General contraindications related to epidural anaesthesia, regardless of the local anaesthetic used, should be taken into account. Intravenous regional anaesthesia. Obstetric paracervical anaesthesia. Hypovolaemia.

Regional anaesthetic procedures should always be performed in a properly equipped and staffed area. Equipment and drugs necessary for monitoring and emergency resuscitation should be immediately available. Patients receiving major blocks should be in an optimal condition and have an intravenous line inserted before the blocking procedure. The clinician responsible should take the necessary precautions to avoid intravascular injection (see section 4.2) and be appropriately trained and familiar with diagnosis and treatment of side effects, systemic toxicity and other complications (see sections 4.8 and 4.9) such as inadvertent subarachnoid injection, which may produce a high spinal block with apnoea and hypotension. Convulsions have occurred most often after brachial plexus block and epidural block. This is likely to be the result of either accidental intravascular injection or rapid absorption from the injection site.

Caution is required to prevent injections in inflamed areas.

Cardiovascular

Epidural and intrathecal anaesthesia may lead to hypotension and bradycardia. Hypotension should be treated promptly with a vasopressor intravenously, and with an adequate vascular filling.

Patients treated with anti-arrhythmic drugs class III (e.g. amiodarone) should be under close surveillance and ECG monitoring considered, since cardiac effects may be additive.

There have been rare reports of cardiac arrest during the use of Naropin for epidural anaesthesia or peripheral nerve blockade, especially after unintentional accidental intravascular administration in elderly patients and in patients with concomitant heart disease. In some instances, resuscitation has been difficult. Should cardiac arrest occur, prolonged resuscitative efforts may be required to improve the possibility of a successful outcome.

Head and neck blocks

Certain local anaesthetic procedures, such as injections in the head and neck regions, may be associated with a higher frequency of serious adverse reactions, regardless of the local anaesthetic used.

Major peripheral nerve blocks

Major peripheral nerve blocks may imply the administration of a large volume of local anaesthetic in highly vascularised areas, often close to large vessels where there is an increased risk of intravascular injection and/or rapid systemic absorption, which can lead to high plasma concentrations.

Hypersensitivity

A possible cross–hypersensitivity with other amide–type local anaesthetics should be taken into account.

Hypovolaemia

Patients with hypovolaemia due to any cause can develop sudden and severe hypotension during epidural anaesthesia, regardless of the local anaesthetic used.

Patients in poor general health

Patients in poor general condition due to ageing or other compromising factors such as partial or complete heart conduction block, advanced liver disease or severe renal dysfunction require special attention, although regional anaesthesia is frequently indicated in these patients.

Patients with hepatic and renal impairment

Ropivacaine is metabolised in the liver and should therefore be used with caution in patients with severe liver disease; repeated doses may need to be reduced due to delayed elimination. Normally there is no need to modify the dose in patients with impaired renal function when used for single dose or short-term treatment.

Acidosis and reduced plasma protein concentration, frequently seen in patients with chronic renal failure, may increase the risk of systemic toxicity.

Acute porphyria

Naropin solution for injection and infusion is possibly porphyrinogenic and should only be prescribed to patients with acute porphyria when no safer alternative is available. Appropriate precautions should be taken in the case of vulnerable patients, according to standard textbooks and/or in consultation with disease area experts.

Chondrolysis

There have been post-marketing reports of chondrolysis in patients receiving post-operative intra-articular continuous infusion of local anaesthetics, including ropivacaine. The majority of reported cases of chondrolysis have involved the shoulder joint. Intra-articular continuous infusion is not an approved indication for Naropin. Intra-articular continuous infusion with Naropin should be avoided, as the efficacy and safety has not been established.

Excipients with recognised action/effect

This medicinal product contains maximum 3.7 mg sodium per ml. To be taken into consideration by patients on a controlled sodium diet.

Prolonged administration

Prolonged administration of ropivacaine should be avoided in patients concomitantly treated with strong CYP1A2 inhibitors, such as fluvoxamine and enoxacin, (see section 4.5).

Paediatric population

Neonates may need special attention due to immaturity of metabolic pathways. The larger variations in plasma concentrations of ropivacaine observed in clinical trials in neonates suggest that there may be an increased risk of systemic toxicity in this age group, especially during continuous epidural infusion. The recommended doses in neonates are based on limited clinical data. When ropivacaine is used in this patient group, regular monitoring of systemic toxicity (e.g. by signs of CNS toxicity, ECG, SpO2) and local neurotoxicity (e.g.  prolonged recovery) is required, which should be continued after ending infusion, due to a slow elimination in neonates.

-  The safety and efficacy of ropivacaine 7.5 mg/ml and 10 mg/ml in children up to and including 12 years has not been established.

-  The safety and efficacy of ropivacaine 2 mg/ml for field block in children up to and including 12 years has not been established.

-  The safety and efficacy of ropivacaine 2 mg/ml for peripheral nerve blocks in infants below 1 year has not been established.


Naropin should be used with caution in patients receiving other local anaesthetics or agents structurally related to amide-type local anaesthetics, e.g. certain antiarrhythmics, such as lidocaine and mexiletine, since the systemic toxic effects are additive. Simultaneous use of Naropin with general anaesthetics or opioids may potentiate each others' (adverse) effects. Specific interaction studies with ropivacaine and anti-arrhythmic drugs class III (e.g. amiodarone) have not been performed, but caution is advised (see also section 4.4).

Cytochrome P450 (CYP) 1A2 is involved in the formation of 3-hydroxy-ropivacaine, the major metabolite. In vivo, the plasma clearance of ropivacaine was reduced by up to 77% during co-administration of fluvoxamine, a selective and potent CYP1A2 inhibitor. Thus strong inhibitors of CYP1A2, such as fluvoxamine and enoxacin given concomitantly during prolonged administration of Naropin, can interact with Naropin. Prolonged administration of ropivacaine should be avoided in patients concomitantly treated with strong CYP1A2 inhibitors, see also section 4.4.

In vivo, the plasma clearance of ropivacaine was reduced by 15% during co-administration of ketoconazole, a selective and potent inhibitor of CYP3A4. However, the inhibition of this isozyme is not likely to have clinical relevance.

In vitro, ropivacaine is a competitive inhibitor of CYP2D6 but does not seem to inhibit this isozyme at clinically attained plasma concentrations.


Pregnancy

Apart from epidural administration for obstetrical use, there are no adequate data on the use of ropivacaine in human pregnancy. Experimental animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/fœtal development, parturition or postnatal development (see section 5.3).

Breastfeeding

There are no data available concerning the excretion of ropivacaine into human milk.


No data are available. Depending on the dose, local anaesthetics may have a minor influence on mental function and co-ordination even in the absence of overt CNS toxicity and may temporarily impair locomotion and alertness.


General

The adverse reaction profile for Naropin is similar to those for other long acting local anaesthetics of the amide type. Adverse drug reactions should be distinguished from the physiological effects of the nerve block itself e.g. a decrease in blood pressure and bradycardia during spinal/epidural block.

Table 4 Table of adverse drug reactions

The frequencies used in the table in Section 4.8 are: 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 (cannot be estimated from the available data).

System Organ Class

Frequency

Undesirable Effect

Immune system disorders

Rare

Allergic reactions (anaphylactic reactions, angioneurotic oedema and urticaria)

Psychiatric disorders

Uncommon

Anxiety

Nervous System disorders

Common

Paraesthesia, Dizziness, Headache

Uncommon

Symptoms of CNS toxicity (Convulsions, Grand mal convulsions, Seizures, Light headedness, Circumoral paraesthesia, Numbness of the tongue, Hyperacusis, Tinnitus, Visual disturbances, Dysarthria, Muscular twitching, Tremor)*, Hypoaesthesia

Not known

Dyskinesia

Cardiac disorders

Common

Bradycardia, Tachycardia

Rare

Cardiac arrest, Cardiac arrhythmias

Vascular disorders

Very common

Hypotensiona

Common

Hypertension

Uncommon

Syncope

Respiratory, Thoracic and Mediastinal disorders

Uncommon

Dyspnoea

Gastrointestinal disorders

Very common

Nausea

Common

Vomitingb

Musculoskeletal and connective tissue disorders

Common

Back pain

Renal and Urinary disorders

Common

Urinary retention

General disorders and Administrative site conditions

Common

Temperature elevation, Chills

Uncommon

Hypothermia

a Hypotension is less frequent in children (>1/100).

b Vomiting is more frequent in children (>1/10).

*  These symptoms usually occur because of inadvertent intravascular injection, overdose or rapid absorption, see section 4.9.

Class-related adverse drug reactions

Neurological complications

Neuropathy and spinal cord dysfunction (e.g. anterior spinal artery syndrome, arachnoiditis, cauda equina), which may result in rare cases of permanent sequelae, have been associated with regional anaesthesia, regardless of the local anaesthetic used.

 

Total spinal block

Total spinal block may occur if an epidural dose is inadvertently administered intrathecally.

Acute systemic toxicity

Systemic toxic reactions primarily involve the central nervous system (CNS) and the cardiovascular system (CVS). Such reactions are caused by high blood concentration of a local anaesthetic, which may appear due to (accidental) intravascular injection, overdose or exceptionally rapid absorption from highly vascularised areas, see also section 4.4. CNS reactions are similar for all amide local anaesthetics, while cardiac reactions are more dependent on the drug, both quantitatively and qualitatively.

Central nervous system toxicity

Central nervous system toxicity is a graded response with symptoms and signs of escalating severity. Initially symptoms such as visual or hearing disturbances, perioral numbness, dizziness, light-headedness, tingling and paraesthesia are seen. Dysarthria, muscular rigidity and muscular twitching are more serious and may precede the onset of generalised convulsions. These signs must not be mistaken for neurotic behaviour.

Unconsciousness and grand mal convulsions may follow, which may last from a few seconds to several minutes. Hypoxia and hypercarbia occur rapidly during convulsions due to the increased muscular activity, together with the interference with respiration. In severe cases even apnoea may occur. The respiratory and metabolic acidosis increases and extends the toxic effects of local anaesthetics.

Recovery follows the redistribution of the local anaesthetic drug from the central nervous system and subsequent metabolism and excretion. Recovery may be rapid unless large amounts of the drug have been injected.

Cardiovascular system toxicity

Cardiovascular toxicity indicates a more severe situation. Hypotension, bradycardia, arrhythmia and even cardiac arrest may occur as a result of high systemic concentrations of local anaesthetics. In volunteers the intravenous infusion of ropivacaine resulted in signs of depression of conductivity and contractility.

Cardiovascular toxic effects are generally preceded by signs of toxicity in the central nervous system, unless the patient is receiving a general anaesthetic or is heavily sedated with drugs such as benzodiazepines or barbiturates.

In children, early signs of local anaesthetic toxicity may be difficult to detect since they may not be able to verbally express them. See also section 4.4.

Paediatric population

Frequency, type and severity of adverse reactions in children are expected to be the same as in adults except for hypotension which happens less often in children (<1 in 10) and vomiting which happens more often in children (>1 in 10).

In children, early signs of local anaesthetic toxicity may be difficult to detect since they may not be able to verbally express them. (See also section 4.4.)

Treatment of acute systemic toxicity

See section 4.9.

To report any side effect(s):

  • Saudi Arabia:

- The National Pharmacovigilance and Drug Safety Centre (NPC):

- Fax: 00966112057662
- SFDA call center 19999
- Toll free phone: 8002490000
- E-mail: npc.drug@sfda.gov.sa
- Website: www.sfda.gov.sa/npc

-  Other GCC States:

- Please contact the relevant competent authority.

 


Symptoms

Accidental intravascular injections of local anaesthetics may cause immediate (within seconds to a few minutes) systemic toxic reactions. In the event of overdose, peak plasma concentrations may not be reached for one to two hours, depending on the site of the injection, and signs of toxicity may thus be delayed. (See section 4.8.)

Treatment

If signs of acute systemic toxicity appear, injection of the local anaesthetic should be stopped immediately and CNS symptoms (convulsions, CNS depression) must promptly be treated with appropriate airway/respiratory support and the administration of anticonvulsant drugs.

If circulatory arrest should occur, immediate cardiopulmonary resuscitation should be instituted. Optimal oxygenation and ventilation and circulatory support as well as treatment of acidosis are of vital importance.

If cardiovascular depression occurs (hypotension, bradycardia), appropriate treatment with intravenous fluids, vasopressor, and or inotropic agents should be considered. Children should be given doses commensurate with age and weight.

Should cardiac arrest occur, a successful outcome may require prolonged resuscitative efforts.


Pharmacotherapeutic group: Anaesthetics, local, Amides

ATC code: N01B B09

Mechanism of action

Ropivacaine is a long-acting, amide-type local anaesthetic with both anaesthetic and analgesic effects. At high doses Naropin produces surgical anaesthesia, while at lower doses it produces sensory block with limited and non-progressive motor block.

The mechanism is a reversible reduction of the membrane permeability of the nerve fibre to sodium ions. Consequently the depolarisation velocity is decreased and the excitable threshold increased, resulting in a local blockade of nerve impulses.

The most characteristic property of ropivacaine is the long duration of action. Onset and duration of the local anaesthetic efficacy are dependent upon the administration site and dose, but are not influenced by the presence of a vasoconstrictor (e.g. adrenaline (epinephrine)). For details concerning the onset and duration of action of Naropin, see Table 1 under posology and method of administration.

Healthy volunteers exposed to intravenous infusions tolerated ropivacaine well at low doses and with expected CNS symptoms at the maximum tolerated dose. The clinical experience with this drug indicates a good margin of safety when adequately used in recommended doses.


Absorption

Ropivacaine has a chiral center and is available as the pure S-(-)-enantiomer. It is highly lipid-soluble. All metabolites have a local anaesthetic effect but of considerably lower potency and shorter duration than that of ropivacaine.

There is no evidence of in vivo racemisation of ropivacaine.

The plasma concentration of ropivacaine depends upon the dose, the route of administration and the vascularity of the injection site. Ropivacaine follows linear pharmacokinetics and the Cmax  is proportional to the dose.

Ropivacaine shows complete and biphasic absorption from the epidural space with half-lives of the two phases of the order of 14 min and 4 h in adults. The slow absorption is the rate-limiting factor in the elimination of ropivacaine, which explains why the apparent elimination half-life is longer after epidural than after intravenous administration. Ropivacaine shows a biphasic absorption from the caudal epidural space also in children.

Distribution

Ropivacaine has a mean total plasma clearance in the order of 440 ml/min, a renal clearance of 1 ml/min, a volume of distribution at steady state of 47 litres and a terminal half-life of 1.8 h after iv administration.

Ropivacaine has an intermediate hepatic extraction ratio of about 0.4. It is mainly bound to α1-acid glycoprotein in plasma with an unbound fraction of about 6%.

An increase in total plasma concentrations during continuous epidural and interscalene infusion has been observed, related to a postoperative increase of α1-acid glycoprotein.

Variations in unbound, i.e. pharmacologically active, concentration have been much less than in total plasma concentration.

Elimination

Since ropivacaine has an intermediate to low hepatic extraction ratio, its rate of elimination should depend on the unbound plasma concentration. A postoperative increase in AAG will decrease the unbound fraction due to increased protein binding, which will decrease the total clearance and result in an increase in total plasma concentrations, as seen in the paediatric and adult studies. The unbound clearance of ropivacaine remains unchanged as illustrated by the stable unbound concentrations during postoperative infusion. It is the unbound plasma concentration that is related to systemic pharmacodynamic effects and toxicity.

Ropivacaine readily crosses the placenta and equilibrium in regard to unbound concentration will be rapidly reached. The degree of plasma protein binding in the foetus is less than in the mother, which results in lower total plasma concentrations in the foetus than in the mother.

Ropivacaine is extensively metabolised, predominantly by aromatic hydroxylation. In total, 86% of the dose is excreted in the urine after intravenous administration, of which only about 1% relates to unchanged drug. The major metabolite is 3-hydroxy-ropivacaine, about 37% of which is excreted in the urine, mainly conjugated.

Urinary excretion of 4-hydroxy-ropivacaine, the N-dealkylated metabolite (PPX) and the 4-hydroxy-dealkylated accounts for 1–3%. Conjugated and unconjugated 3-hydroxy-ropivacaine shows only detectable concentrations in plasma.

A similar pattern of metabolites has been found in children above one year.

Impaired renal function has little or no influence on ropivacaine pharmacokinetics. The renal clearance of PPX is significantly correlated with creatinine clearance. A lack of correlation between total exposure, expressed as AUC, with creatinine clearance indicates that the total clearance of PPX includes a non-renal elimination in addition to renal excretion. Some patients with impaired renal function may show an increased exposure to PPX resulting from a low non-renal clearance. Due to the reduced CNS toxicity of PPX as compared to ropivacaine the clinical consequences are considered negligible in short-term treatment. Patients with end- stage renal disease undergoing dialysis have not been studied.

Paediatrics

The pharmacokinetics of ropivacaine was characterized in a pooled population PK analysis on data in 192 children between 0 and 12 years. Unbound ropivacaine and PPX clearance and ropivacaine unbound volume of distribution depend on both body weight and age up to the maturity of liver function, after which they depend largely on body weight. The maturation of unbound ropivacaine clearance appears to be complete by the age of 3 years, that of PPX by the age of 1 year and unbound ropivacaine volume of distribution by the age of 2 years. The PPX unbound volume of distribution only depends on body weight. As PPX has a longer half-life and a lower clearance, it may accumulate during epidural infusion.

Unbound ropivacaine clearance (Clu) for ages above 6 months has reached values within the range of those in adults. Total ropivacaine clearance (CL) values displayed in Table 5 are those not affected by the postoperative increase in AAG.

Table 5 Estimates of pharmacokinetic parameters derived from the pooled paediatric population PK analysis

Age Group

BWa

Club

Vuc

CLd

t1/2e

t1/2ppxf

kg

(L/h/kg)

(L/kg)

(L/h/kg)

(h)

(h)

Newborn

3.27

2.40

21.86

0.096

6.3

43.3

1m

4.29

3.60

25.94

0.143

5.0

25.7

6m

7.85

8.03

41.71

0.320

3.6

14.5

1y

10.15

11.32

52.60

0.451

3.2

13.6

4y

16.69

15.91

65.24

0.633

2.8

15.1

10y

32.19

13.94

65.57

0.555

3.3

17.8

a Median bodyweight for respective age from WHO database.

b Unbound ropivacaine clearance.

c Ropivacaine unbound volume of distribution.

d Total ropivacaine  clearance.

e Ropivacaine terminal half life. 

f PPX terminal half life.

The simulated mean unbound maximal plasma concentration (Cumax) after a single caudal block tended to be higher in neonates and the time to Cumax  (tmax) decreased with an increase in age (Table 6). Simulated mean unbound plasma concentrations at the end of a 72 h continuous epidural infusion at recommended dose rates also showed higher levels in neonates as compared to those in infants and children. See also section 4.4.

Table 6 Simulated mean and observed range of unbound Cumax  after a single caudal block

Age Group

Dose

Cumaxa

tmaxb

Cumaxc

(mg/kg)

(mg/L)

(h)

(mg/L)

0-1m

2.00

0.0582

2.00

0.05-0.08 (n=5)

1-6m

2.00

0.0375

1.50

0.02-0.09 (n=18)

6-12m

2.00

0.0283

1.00

0.01-0.05 (n=9)

1-10y

2.00

0.0221

0.50

0.01-0.05 (n=60)

a Unbound maximal plasma concentration.

b Time to unbound maximal plasma concentration.

c Observed and dose-normalised unbound maximal plasma concentration.

At 6 months, the breakpoint for change in the recommended dose rate for continuous epidural infusion, unbound ropivacaine clearance has reached 34% and unbound PPX 71% of its mature value. The systemic

exposure is higher in neonates and also somewhat higher in infants between 1 to 6 months compared to older children, which is related to the immaturity of their liver function. However, this is partly compensated for by the recommended 50% lower dose rate for continuous infusion in infants below 6 months.

Simulations on the sum of unbound plasma concentrations of ropivacaine and PPX, based on the PK parameters and their variance in the population analysis, indicate that for a single caudal block the recommended dose must be increased by a factor of 2.7 in the youngest group and a factor of 7.4 in the 1 to 10 year group in order for the upper prediction 90% confidence interval limit to touch the threshold for systemic toxicity. Corresponding factors for the continuous epidural infusion are 1.8 and 3.8 respectively.

Simulations on the sum of unbound plasma concentrations of ropivacaine and PPX, based on the PK parameters and their variance in the population analysis, indicate that for 1- to 12- year-old infants and children receiving 3 mg/kg single peripheral (ilioinguinal) nerve block the median unbound peak concentration reached after 0.8 h is 0.0347 mg/L, one-tenth of the toxicity threshold (0.34 mg/L). The upper 90% confidence interval for the maximum unbound plasma concentration is 0.074 mg/L, one-fifth of the toxicity threshold. Similarly, for continuous peripheral block (0.6 mg ropivacaine/kg for 72 h) preceded by a 3 mg/kg single peripheral nerve block, the median unbound peak concentration is 0.053 mg/L. The upper 90% confidence interval for the maximum unbound plasma concentration is 0.088 mg/L, one-quarter of the toxicity threshold.

 


Based on conventional studies of safety pharmacology, single and repeated dose toxicity, reproduction toxicity, mutagenic potential and local toxicity, no hazards for humans were identified other than those which can be expected on the basis of the pharmacodynamic action of high doses of ropivacaine (e.g. CNS signs, including convulsions, and cardiotoxicity).


Sodium chloride

Hydrochloric acid

Sodium hydroxide

Water for injections


In alkaline solutions precipitation may occur as ropivacaine shows poor solubility at pH > 6.


3 years. Shelf life after first opening: 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 normally not be longer than 24 hours at 2–8°C.

Do not store above 30°C. Do not freeze.

For storage after opening, see section 6.3.


10 ml polypropylene ampoules (Polyamp) in packs of 5 and 10.

10 ml polypropylene ampoules (Polyamp) in sterile blister packs of 5 and 10.

20 ml polypropylene ampoules (Polyamp) in packs of 5 and 10.

20 ml polypropylene ampoules (Polyamp) in sterile blister packs of 5 and 10.

Not all pack sizes may be marketed.

The polypropylene ampoules (Polyamp) are specially designed to fit Luer lock and Luer fit syringes.


Naropin products are preservative-free and are intended for single use only. Discard any unused solution.

The intact container must not be re-autoclaved. A blistered container should be chosen when a sterile outside is required.

The medicinal product should be visually inspected prior to use. The solution should only be used if it is clear, practically free from particles and if the container is undamaged.


Aspen Pharma Trading Limited, 3016 Lake Drive, Citywest Business Campus, Dublin 24, Ireland

11/09/2018
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