Amiodarone 30mg/ml Solution for injection/infusion in pre-filled syringe – Summary of Product Characteristics (SmPC) for healthcare professionals

1 NAME OF THE MEDICINAL PRODUCT

Amiodarone 30mg/ml Solution for injection/infusion in pre-filled syringe

2 QUALITATIVE AND QUANTITATIVE COMPOSITION

Each 10ml pre-filled syringe contains 300mg amiodarone hydrochloride equivalent to 30mg amiodarone hydrochloride per ml.

Excipients:

Each pre-filled syringe contains 112mg of iodine.

Excipients with known effect:

Benzyl alcohol: This medicinal product contains 200mg in each 10ml pre-filled syringe.

For the full list of excipients, see section 6.1.

3 PHARMACEUTICAL FORM

Solution for injection/infusion

Amiodarone 30mg/ml Injection is a clear, slightly yellow solution, practically free from particulates.

4.1 Therapeutic indications

Amiodarone is indicated only for the treatment of severe cardiac rhythm disorders not responding to other therapies or when other treatments cannot be used.

• AV nodal arrhythmias and AV re-entrant tachycardia tachycardia, e.g. as a manifestation of Wolff-Parkinson-White (WPW) syndrome.
• All types of tachyarrhythmias including supraventricular, nodal and ventricular tachycardias; atrial flutter and fibrillation; life-threatening ventricular arrythmias (including persistent or non-persistent ventricular tachycardia or episodes of ventricular fibrillation).

Amiodarone Hydrochloride 30mg/ml injection can be used where a rapid response is required or where oral administration is not possible.

Amiodarone may be used prior to DC cardioversion.

4.2 Posology and method of administration

Treatment should be initiated and normally monitored only under hospital or specialist supervision. Amiodarone should only be used when facilities exist for cardiac monitoring, defibrillation, and cardiac pacing.

Posology

The standard recommended dose is 5mg/kg bodyweight given by intravenous infusion over a period of 20 minutes to 2 hours. This should be administered as a dilute solution in 250ml 5% w/v dextrose. This may be followed by repeat infusion up to 1200mg (approximately 15mg/kg bodyweight) in up to 500ml 5% w/v dextrose per 24 hours; the rate of infusion being adjusted on the basis of clinical response (see section 4.4).

In extreme clinical emergency, the drug may, at the discretion of the clinician, be given as a slow injection of 150-300mg in 10-20ml 5%w/v dextrose over a minimum of 3 minutes. This should not be repeated for at least 15 minutes. Patients treated in this way with Amiodarone must be closely monitored, e.g. in an intensive care unit (see section 4.4).

Cardiopulmonary resuscitation:

The recommended dose for ventricular fibrillations/pulseless ventricular tachycardia resistant to defibrillation is 300 mg (or 5 mg/kg body-weight) as a rapid injection. An additional 150 mg (or 2.5 mg/kg body-weight) IV dose may be considered if ventricular fibrillation persists. See section 6.2 for information on incompatibilities

Changeover from Intravenous to Oral therapy:

As soon as an adequate response has been obtained, oral therapy should be initiated concomitantly at the usual loading dose (i.e. 200mg three times a day). Amiodarone injection should then be phased out gradually.

Paediatric population:

The safety and efficacy of amiodarone in children and adolescents has not been established. Currently available data are described in sections 5.1 and 5.2. Due to the presence of benzyl alcohol, intravenous amiodarone is usually contraindicated in neonates and should be used with caution in infants and children up to 3 years old. (see section 4.3).

No controlled paediatric studies have been undertaken. In published uncontrolled studies, effective doses for children were:

Loading dose: 5mg/kg body weight over 20 minutes to 2 hours

Maintenance dose: 10 to 15mg/kg/day from a few hours to several days. If needed, oral therapy may be initiated concomitantly.

Elderly:

As with all patients, it is important that the minimum effective dose is used. Whilst there is no evidence that dosage requirements are different for this group of patients, they may be more susceptible to bradycardia and conduction defects if too high a dose is employed. Particular attention should be paid to monitoring thyroid function (see sections 4.3, 4.4 and 4.8).

Hepatic and renal impairment:

Method of administration:

4.3 Contraindications

• Hypersensitivity to the active substance, iodine or to any of the excipients listed in section 6.1 (one pre-filled syringe contains approximately 112mg iodine).
• Sinus bradycardia, sino-atrial heart block and sick sinus syndrome in patients without a pacemaker. In patients with severe conduction disturbances (high grade AV block, bifascicular or trifascicular block) or sinus node disease, amiodarone should be used only in specialized units in conjunction with a pacemaker.
• Evidence or history of thyroid dysfunction (see section 4.2 and 4.4).
• Severe respiratory failure, circulatory collapse, or severe arterial hypotension; hypotension, heart failure and cardiomyopathy are also contra-indications when using amiodarone as a bolus injection
• The concomitant administration of amiodarone with drugs which may prolong the QT interval (see section 4.5)
• Due to the presence of benzyl alcohol, intravenous amiodarone is contraindicated in neonates and should be used with caution in infants and children up to 3 years old (see section 4.4).
• Pregnancy and lactation – The use is allowed only in special life-threatening circumstances as specified in sections 4.1, 4.4, 4.6

All these above contra-indications do not apply to the use of amiodarone for cardiopulmonary resuscitation of shock resistant ventricular fibrillation.

4.4 Special warnings and precautions for use

The prefilled syringes must be used with compatible needle-free connectors (NFCs).

Using an incompatible NFC may lead to blockages, potentially delaying the delivery of emergency medication.

To avoid such issues, ensure compatible NFCs are procured in advance and stored together with the Aurum range of prefilled syringes.

List of compatible NFCs can be found in the link below:

https://ethypharm.co.uk/files/aurum-connector-compatibility-chart.pdf

Administration:

Amiodarone injection should only be used in a special care unit under continuous monitoring (ECG and blood pressure).

IV infusion is preferred to bolus due to the haemodynamic effects sometimes associated with rapid injection (see section 4.8). Circulatory collapse may be precipitated by too rapid administration or overdosage (atropine has been used successfully in such patients presenting with bradycardia). Repeated or continuous infusion via peripheral veins may lead to injection site reactions (see section 4.8). When repeated or continuous infusion is anticipated, administration by a central venous catheter is recommended.

Amiodarone should not be mixed with other preparations in the same syringe and should not be injected with other preparations in the same line. If treatment with amiodarone should be continued, this should be via intravenous infusion (see section 4.2).

When given by infusion amiodarone hydrochloride may reduce drop size and, if appropriate, adjustments should be made to the rate of infusion.

Anaesthesia:

Before surgery, the anaesthetist should be informed that the patient is being treated with amiodarone (see section 4.5).

Cardiac disorders:

Caution should be exercised in patients with hypotension and decompensated cardiomyopathy and severe heart failure (see section 4.3).

Too high a dosage may lead to severe bradycardia and to conduction disturbances with the appearance of an idioventricular rhythm, particularly in elderly patients or during digitalis therapy. In these circumstances, amiodarone treatment should be withdrawn. If necessary beta-adrenostimulants or glucagon may be given. Because of the long half-life of amiodarone, if bradycardia is severe and symptomatic the insertion of a pacemaker should be considered.

Amiodarone has a low pro-arrhythmic effect. Onsets of new arrhythmias or worsening of treated arrhythmias, sometimes fatal, have been reported. It is important, but difficult to differentiate a lack of efficacy of the drug from a proarrhythmic effect, whether or not this is associated with a worsening of the cardiac condition. Proarrhythmic effects generally occur in the context of QT prolongation factors such as drug interactions and/or electrolytic disorders (see sections 4.5 and 4.8). Despite QT interval prolongation, amiodarone exhibits a low torsadogenic activity.

The pharmacological action of amiodarone induces ECG changes:

QT prolongation (related to prolonged repolarisation) with the possible development of U-waves and deformed T-waves; these changes do not reflect toxicity.

Severe bradycardia and heart block after sofosbuvir

Life-threatening cases of bradycardia and heart block have been observed when sofosbuvir-containing regimens are used in combination with amiodarone.

Bradycardia has generally occurred within hours to days, but later cases have been mostly observed up to 2 weeks after initiating HCV treatment.

Amiodarone should only be used in patients on sofosbuvir-containing regimen when other alternative anti-arrhythmic treatments are not tolerated or are contraindicated.

Should concomitant use of amiodarone be considered necessary, it is recommended that patients undergo cardiac monitoring in an in-patient setting for the first 48 hours of coadministration, after which outpatient or self-monitoring of the heart rate should occur on a daily basis through at least the first 2 weeks of treatment.

Due to the long half-life of amiodarone, cardiac monitoring as outlined above should also be carried out for patients who have discontinued amiodarone within the past few months and are to be initiated on sofosbuvir- containing regimen.

All patients receiving amiodarone in combination with sofosbuvir-containing regimen should be warned of the symptoms of bradycardia and heart block and should be advised to seek medical advice urgently should they experience them.

Primary graft dysfunction (PGD) post cardiac transplant:

In retrospective studies, amiodarone use in the transplant recipient prior to heart transplant has been associated with an increased risk of PGD.

PGD is a life-threatening complication of heart transplantation that presents as a left, right or biventricular dysfunction occurring within the first 24 hours of transplant surgery for which there is no identifiable secondary cause (see section 4.8). Severe PGD may be irreversible.

For patients who are on the heart transplant waiting list, consideration should be given to use an alternative antiarrhythmic drug as early as possible before transplant.

General anaesthesia:

Caution is advised in patients undergoing general anaesthesia, or receiving high dose oxygen therapy.

Potentially severe complications have been reported in patients taking amiodarone undergoing general anaesthesia: bradycardia unresponsive to atropine, hypotension, disturbances of conduction, decreased cardiac output (see section 4.5).

Endocrine disorders (see section 4.8):

Amiodarone may induce hyperthyroidism, particularly in patients with a personal history of thyroid disorders or patients who are taking/have previously taken oral amiodarone. Serum ultrasensitive thyroid-stimulating hormone (usTSH) level should be measured when thyroid dysfunction is suspected. Thyroid function tests should be performed where appropriate prior to therapy in all patients.

Amiodarone contains iodine and thus may interfere with radio-iodine uptake. However, thyroid function tests (free-T3, free-T4, usTSH) remain interpretable. Amiodarone inhibits peripheral conversion of thyroxine (T4) to triiodothyronine (T3) and may cause isolated biochemical changes (increase in serum free-T4, free-T3 being slightly decreased or even normal) in clinically euthyroid patients. There is no reason in such cases to discontinue amiodarone treatment if there is no clinical or further biological (usTSH) evidence of thyroid disease.

In case of additional side effects such as weight loss, asthenia, restlessness, increase in heart rate, recurrence of the cardiac dysrhythmia, angina, or congestive heart failure, clinician should be alerted.

Respiratory, thoracic and mediastinal disorders (see section 4.8):

Onset of dyspnoea or non-productive cough may be related to pulmonary toxicity such as interstitial pneumonitis.

Very rare cases of interstitial pneumonitis have been reported with intravenous amiodarone. When the diagnosis is suspected, a chest X-ray should be performed. Amiodarone therapy should be re-evaluated since interstitial pneumonitis is generally reversible following early withdrawal of amiodarone, and corticosteroid therapy should be considered (see section 4.8). Clinical symptoms often resolve within a few weeks followed by slower radiological and lung function improvement. Some patients can deteriorate despite discontinuing amiodarone hydrochloride. Fatal cases of pulmonary toxicity have been reported.

Very rare cases of severe respiratory complications, sometimes fatal, have been observed usually in the period immediately following surgery (adult acute respiratory distress syndrome); a possible interaction with a high oxygen concentration may be implicated (see sections 4.5 and 4.8).

Hepato-biliary disorders (see section 4.8):

Severe hepatocellular insufficiency may occur within the first 24 hours of IV amiodarone, and may sometimes be fatal. Close monitoring of transaminases is therefore recommended as soon as amiodarone is started.

Severe bullous reactions:

Life-threatening or even fatal cutaneous reactions: Stevens-Johnson syndrome (SJS), Toxic Epidermal Necrolysis (TEN) (see section 4.8). If symptoms or signs of SJS, TEN (e.g. progressive skin rash often with blisters or mucosal lesions) are present, amiodarone treatment should be discontinued immediately.

Eye disorders (see section 4.8):

If blurred or decreased vision occurs, complete ophthalmologic examination including fundoscopy should be promptly performed. Appearance of optic neuropathy and/or optic neuritis requires amiodarone withdrawal due to the potential progression to blindness.

Severe bradycardia and heart block

Life-threatening cases of bradycardia and heart block have been observed when sofosbuvir-containing regimens are used in combination with amiodarone.

Bradycardia has generally occurred within hours to days, but later cases have been mostly observed up to 2 weeks after initiating hepatitis C virus (HCV) treatment.

Amiodarone should only be used in patients on sofosbuvir- containing regimen when other alternative anti-arrhythmic treatments are not tolerated or are contraindicated.

Should concomitant use of amiodarone be considered necessary, it is recommended that patients undergo cardiac monitoring in an in-patient setting for the first 48 hours of coadministration, after which outpatient or self-monitoring of the heart rate should occur on a daily basis through at least the first 2 weeks of treatment.

Due to the long half-life of amiodarone, cardiac monitoring as outlined above should also be carried out for patients who have discontinued amiodarone within the past few months and are to be initiated on sofosbuvir- containing regimen.

All patients receiving amiodarone in combination with sofosbuvir-containing regimen should be warned of the symptoms of bradycardia and heart block and should be advised to seek medical advice urgently should they experience them.

Drug interactions (see section 4.5)

Concomitant use of amiodarone with the following drugs is not recommended; beta-blockers, heart rate lowering calcium channel inhibitors (verapamil, diltiazem), stimulant laxative agents which may cause hypokalaemia.

In cases of hypokalaemia, corrective action should be taken and QT interval monitored. In case of torsade de pointes antiarrhythmic agents should not be given; pacing may be instituted and IV magnesium may be used.

Increased plasma levels of flecainide have been reported with co-administration of amiodarone. The flecainide dose should be reduced accordingly and the patient closely monitored.

Contains benzyl alcohol (20 mg/ml)

This medicine contains 200mg of benzyl alcohol in each 10ml syringe. Benzyl alcohol may cause allergic reactions. The minimum amount of benzyl alcohol at which toxicity may occur is not known with an increased risk in young children due to accumulation.

The administration of medications containing benzyl alcohol to newborns or premature neonates has been associated with serious adverse events and a fatal “Gasping Syndrome” (symptoms include a striking onset of gasping syndrome, hypotension, bradycardia and cardio-vascular collapse).

As benzyl alcohol may cross the placenta, this medicinal product should be used with caution in pregnancy.

High volumes should be used with caution and only if necessary, especially in subjects with liver or kidney impairment or those who are pregnant or breast-feeding because of the risk of accumulation and toxicity (metabolic acidosis).

Primary Graft Dysfunction post cardiac transplant

In retrospective studies, amiodarone use in the transplant recipient prior to heart transplant has been associated with an increased risk of primary graft dysfunction (PGD). PGD is a life-threatening complication of heart transplantation that presents as left, right or biventricular dysfunction occurring within the first 24 hours of transplant surgery for which there is no identifiable secondary cause (see Section 4.8). Severe PGD may be irreversible. For patients who are on the heart transplant waiting list, consideration should be given to use an alternative antiarrhythmic drug as early as possible before transplant.

4.5 Interaction with other medicinal products and other forms of interaction

Drugs inducing “Torsade de Pointes” or prolonging the QT interval

Some of the more important drugs that interact with amiodarone include warfarin, digoxin, phenytoin and any drug which prolongs the QT interval.

Combined therapy with the following drugs which prolong the QT interval is contra- indicated (see section 4.3) due to the increased risk of torsades de pointes; for example:

• Class Ia anti-arrhythmic drugs e.g. quinidine, procainamide, disopyramide
• Class III anti-arrhythmic drugs e.g. sotalol, bretylium
• Intravenous erythromycin, co-trimoxazole or pentamidine injection
• Some anti-psychotics e.g. chlorpromazine, thioridazine, fluphenazine, pimozide, haloperidol, amisulpride and sertindole
• Lithium and tricyclic anti-depressants e.g. doxepin, maprotiline, amitriptyline
• Certain antihistamines e.g. terfenadine, astemizole, mizolastine
• Anti-malarials e.g. quinine, mefloquine, chloroquine, halofantrine
• Moxifloxacin

Drugs lowering heart rate, causing automaticity or conduction disorders Combined therapy with the following drugs is not recommended;

• Beta blockers and certain calcium channel blockers (diltiazem, verapamil); potentiation of negative chronotropic properties and conduction slowing effects may occur.
• Sofosbuvir: Coadministration of amiodarone with sofosbuvir-containing regiments may lead to serious symptomatic bradycardia. If coadministration cannot be avoided, cardiac monitoring is recommended (see section 4.4).
• Stimulant laxatives may cause hypokalaemia thus increasing the risk of torsades de pointes; other types of laxatives should be used.

• Combined therapy with the following drugs which may also cause hypokalaemia and/or hypomagnesaemia should be considered with caution:

  • diuretics,
  • systemic corticosteroids,
  • tetracosactrin,
  • intravenous amphotericin B.

General anaesthesia

(see section 4.4). Very rare cases of severe respiratory complications (adult acute respiratory distress syndrome), sometimes fatal, have been observed usually in the period immediately following surgery. A possible interaction with a high oxygen concentration may be implicated (see section 4.4).

PgP Substrates

Amiodarone is a P-gp inhibitor. Co administration with P-gp substrates is expected to result in an increase in their exposure.

Digoxin

Administration of amiodarone injection to a patient already receiving digoxin will bring about an increase in the plasma digoxin concentration and thus precipitate symptoms and signs associated with high digoxin levels; disturbances in automaticity (excessive bradycardia) a synergistic effect on heart rate and atrioventricular conduction may occur. Clinical ECG and biological monitoring is recommended to observe for signs of cardiac glycoside toxicity and digoxin dosage should be halved.

Dabigatran

Warfarin

The dose of warfarin should be reduced accordingly. More frequent monitoring of prothrombin time both during and after amiodarone treatment is recommended.

Phenytoin

Phenytoin dosage should be reduced if signs of overdosage appear and plasma levels may be measured.

CYP2D6 substrates

Flecainide

,

CYP P450 3A4 substrates When drugs are co-administered with amiodarone, an inhibitor of CYP 3A4, this may result in a higher level of their plasma concentrations, which may lead to a possible increase in their toxicity:

•

in

•

h

metabolised by CYP 3A4 when given with amiodarone.Other drugs metabolised by cytochrome P450 3A4: examples of such drugs are lidocaine, tacrolimus, sildenafil,

Interaction with substrates of other CYP 450 isoenzymes

n

Other drug interactions with amiodarone (see section 4.4)

Coadministration of amiodarone with sofosbuvir-containing regimens may lead to serious

).

4.6 Fertility, pregnancy and lactation

Pregnancy

a

Breast-feeding

Amiodarone and its active metabolite are excreted into the breast milk in significant quantities. If therapy is required during the lactation period, or if amiodarone was taken

4.7 Effects on ability to drive and use machines

Amiodarone hydrochloride may affect the ability to drive or use machines.

4.8 Undesirable effects

The most common adverse drug effects reported with intravenous amiodarone hydrochloride are infusion phlebitis, bradycardia, and hypotension.

Frequency of the adverse reaction listed below is defined according to the following convention:

very common (≥1/10);

common (≥1/100 to <1/10);

uncommon (≥1/1,000 to <1/100);

rare (≥ 1/10,000 to <1/1,000);

very rare (<1/10,000);

not known (cannot be estimated from the available data)

Table 1: Frequency of the adverse reaction

A few rare cases with various clinical symptoms, indicative of hypersensitivity reactions, have been reported: vasculitis, reduced renal function with a rise in creatinine levels, thrombocytopenia, anaphylaxis.

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 Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9 Overdose

There is no information regarding overdosage with intravenous amiodarone.

Few cases of sinus bradycardia, heart block, attacks of ventricular tachycardia, torsades de pointes, circulatory failure and hepatic injury have been reported.

The patient should be monitored and if bradycardia occurs beta- adrenostimulants or glucagon may be given Spontaneously resolving attacks of ventricular tachycardia may also occur.

Due to the pharmacokinetics of amiodarone, adequate and prolonged surveillance of the patient, particularly their cardiac status, is recommended. Neither amiodarone nor its metabolites are dialysable.

5 PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Cardiac therapy,

antiarrhythmics, class III

ATC Code: CO1BDO1

α

In the ARREST study, 504 patients – with out-of-hospital cardiac arrest as a result of ventricular fibrillation, or pulseless ventricular tachycardia refractory to 3 or more defibrillator shocks and epinephrine – were given either 300 mg amiodarone diluted in 20 ml 5% glucose as a rapid injection into a peripheral vein (246 patients) or placebo (258 patients). Of the 197 patients (39%) who survived the journey to hospital, amiodarone

Paediatric population:

No controlled paediatric studies have been undertaken.

In published studies the safety of amiodarone was evaluated in 1118 paediatric patients with various arrhythmias. The following doses were used in paediatric clinical trials:

Oral

• Loading dose: 10 to 20 mg/kg/day for 7 to 10 days (or 500 mg/m2/day if expressed per square meter)
• Maintenance dose: the minimum effective dosage should be used; according to individual response, it may range between 5 to 10 mg/kg/day (or 250 mg/m2/day if expressed per square meter)

Intravenous

• Loading dose: 5 mg/kg body weight over 20 minutes to 2 hours
• Maintenance dose: 10 to 15 mg/kg/day from few hours to several days

If needed, oral therapy may be initiated concomitantly at the usual loading dose.

5.2 Pharmacokinetic properties

Pharmacokinetics of amiodarone are unusual and complex, and have not been completely elucidated.

Intravenous administration

Because of these characteristics the recommended saturating dosage should be given in order to reach fast saturation of the tissue which is the prerequisite for therapeutic efficacy. Amiodarone is highly protein bound (> 95%).

After discontinuation amiodarone is excreted over several months.

A study in both healthy volunteers and patients after intravenous administration of amiodarone reported that the calculated volumes of distribution and total blood clearance using a two-compartment open model were similar for both groups. Elimination of amiodarone after intravenous injection appeared to be biexponential with a distribution phase lasting about 4 hours. The very high volume of distribution combined with a relatively low apparent volume for the central compartment suggests extensive tissue distribution. A bolus IV injection of 400mg gave a terminal T½ of approximately 11 hours.

Paediatric population

No controlled paediatric studies have been undertaken. In the limited published data available in paediatric patients, there were no differences noted compared to adults.

5.3 Preclinical safety data

6 PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Polysorbate 80

Benzyl alcohol

Water for Injections

6.2 Incompatibilities

Amiodarone is incompatible with saline and should be administered solely in a 5% w/v dextrose solution.

Amiodarone, diluted with 5% dextrose solution to a concentration of less than 0.6mg/ml, is unstable. Solutions containing less than 1 pre-filled syringe of Amiodarone in 500ml dextrose 5% are unstable and should not be used.

The use of administration equipment or devices containing plasticizers such as DEHP (di-2-ethylhexyphthalate) in the presence of amiodarone may result in leaching out of DEHP. In order to minimise patient exposure to DEHP, the final amiodarone dilution for infusion should preferably be administered through non DEHP-containing sets such as polyolefin (PE, PP) or glass sets. No other agents may be added to amiodarone infusions.

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

6.3 Shelf life

18 months

From a microbiological point of view, the product should be used immediately. For single use only. Any unused solution from opened ampoules should be discarded.

6.4 Special precautions for storage

Do not store above 25°C. Store the syringe in the outer carton until needed.

6.5 Nature and contents of container

10ml type 1 glass pre-filled syringe with rubber stopper and rubber tip cap.

6.6 Special precautions for disposal

Amiodarone 30mg/ml Injection is intended for single dose use only. Any unused solution should be discarded immediately after initial use.

7 MARKETING AUTHORISATION HOLDER

Aurum Pharmaceuticals Ltd

T/A Martindale Pharma

Bampton Road

Harold Hill

Romford

Essex RM3 8UG

United Kingdom

8 MARKETING AUTHORISATION NUMBER(S)

PL 12064/0047

9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE

AUTHORISATION

Date of first authorisation: 23 November 2000

10 DATE OF REVISION OF THE TEXT

20/08/2025