CALCIUM FOLINATE 10 MG / ML SOLUTION FOR INJECTION - summary of medicine characteristics

Calcium Folinate 10 mg/ml Solution for Injection

2 QUALITATIVE AND QUANTITATIVE COMPOSITION

Calcium folinate is a mixture of the two enantiomers, the bioactive (S)-folinate and the inactive ®-folinate.

1 ml of Calcium Folinate 10 mg/ml Solution for Injection contains 10.8 mg of Calcium Folinate, equivalent to 10.0 mg of folinic acid.

5 ml solution contains 54 mg Calcium Folinate, equivalent to 50 mg folinic acid.

10 ml solution contains 108 mg Calcium Folinate, equivalent to 100 mg folinic acid.

20 ml solution contains 216 mg Calcium Folinate, equivalent to 200 mg folinic acid.

35 ml solution contains 378 mg Calcium Folinate, equivalent to 350 mg folinic acid.

50 ml solution contains 540 mg Calcium Folinate, equivalent to 500 mg folinic acid.

100 ml solution contains 1080 mg Calcium Folinate, equivalent to 1000 mg folinic acid.

For a full list of excipients, see section 6.1

Solution for injection or infusion.

The solution is a clear yellow solution, practically free from particles.

4.1

Therapeutic indications

Calcium folinate is indicated

to diminish the toxicity and counteract the action of folic acid antagonists such as methotrexate in cytotoxic therapy and overdose in adults and children. In cytotoxic therapy, this procedure is commonly known as “Calcium Folinate Rescue”;

in combination with 5-fluorouracil in cytotoxic therapy.

4.2 Posology and method of administration

For intravenous and intramuscular administration only. In the case of intravenous administration, no more than 160 mg of calcium folinate should be injected per minute due to the calcium content of the solution.

For intravenous infusion, Calcium Folinate 10 mg/ml Solution for Injection may be diluted with 0.9% Sodium Chloride Injection or 5% Glucose Injection before use. Refer also to sections 6.3 and 6.6.

Calcium folinate rescue in methotrexate therapy:

Since the calcium folinate rescue dosage regimen depends heavily on the posology and method of the intermediate- or high-dose methotrexate administration, the methotrexate protocol will dictate the dosage regimen of calcium folinate rescue.

Therefore, it is best to refer to the applied intermediate or high dose methotrexate protocol for posology and method of administration of calcium folinate.

The following guidelines may serve as an illustration of regimens used in adults, elderly and children:

Calcium folinate rescue has to be performed by parenteral administration in patients with malabsorption syndromes or other gastrointestinal disorders where enteral absorption is not assured. Dosages above 25–50 mg should be given parenterally due to saturable enteral absorption of calcium folinate.

Calcium folinate rescue is necessary when methotrexate is given at doses exceeding 500 mg/m2 body surface and should be considered with doses of 100 mg – 500 mg/m2 body surface.

Dosage and duration of calcium folinate rescue primarily depend on the type and dosage of methotrexate therapy, the occurrence of toxicity symptoms, and the individual excretion capacity for methotrexate. As a rule, the first dose of calcium folinate is 15 mg (6 – 12 mg/m2) to be given 12–24 hours (24 hours at the latest) after the beginning of methotrexate infusion. The same dose is given every 6 hours throughout a period of 72 hours. After several parenteral doses, treatment can be switched over to the oral form.

In addition to calcium folinate administration, measures to ensure the prompt excretion of methotrexate (maintenance of high urine output and alkalinisation of urine) are integral parts of the calcium folinate rescue treatment. Renal function should be monitored through daily measurements of serum creatinine.

Forty-eight hours after the start of the methotrexate infusion, the residual methotrextae-level should be measured. If the residual methotrexate-level is >0.5 |imol/l, calcium folinate dosages should be adapted according to the following table:

In combination with 5-fluorouracil in cytotoxic therapy :

Different regimens and different dosages are used, without any dosage having been proven to be the optimal one.

The following regimens have been used in adults and elderly in the treatment of advanced or metastatic colorectal cancer and are given as examples. There are no data on the use of these combinations in children:

Bimonthly regimen: Calcium folinate 200 mg/m2 by intravenous infusion over two hours, followed by bolus 400 mg/m2 of 5-FU and 22-hour infusion of 5-FU (600 mg/m2) for 2 consecutive days, every 2 weeks on days 1 and 2.

Weekly regimen: Calcium folinate 20 mg/m2 by bolus i.v. injection or 200 to 500 mg/m2 as i.v. infusion over a period of 2 hours plus 500 mg/im 5-fluorouracil as i.v. bolus injection in the middle or at the end of the calcium folinate infusion.

Monthly regimen: Calcium folinate 20 mg/m2 by bolus i.v. injection or 200 to 500 mg/m2 as i.v. infusion over a period of 2 hours immediately followed by 425 or 370 mg/m2 5-fluorouracil as i.v. bolus injection during five consecutive days.

For the combination therapy with 5-fluorouracil, modification of 5-fluorouracil dosage and the treatment-free interval may be necessary depending on patient condition, clinical response and dose limiting toxicity as stated in the product information of 5-fluorouracil.

A reduction of calcium folinate dosage is not required.

The number of repeat cycles used is at the discretion of the clinician.

Antidote to the  folic acid antagonists trimetrexate, trimethoprime, and pyrimethamine:

Trimetrexate toxicity:

Prevention: Calcium folinate should be administered every day during treatment with trimetrexate and for 72 hours after the last dose of trimetrexate. Calcium folinate can be administered either by the intravenous route at a dose of 20 mg/m2 for 5 to 10 minutes every 6 hours for a total daily dose of 80 mg/itf, or by oral route with four doses of 20 mg/m2 administered at equal time intervals. Daily doses of calcium folinate should be adjusted depending on the haematological toxicity of trimetrexate.

Overdosage (possibly occurring with trimetrexate doses above 90 mg/m2 without concomitant administration of calcium folinate): after stopping trimetrexate, calcium folinate 40 mg/m2 IV every 6 hours for 3 days.

Trimethoprime toxicity:

After stopping trimethoprime, 3–10 mg/day calcium folinate until recovery of a normal blood count.

Pyrimethamine toxicity:

In case of high dose pyrimethamine or prolonged treatment with low doses, calcium folinate 5 to 50 mg/day should be simultaneously administered, based on the results of the peripheral blood counts.

4.3 Contraindications

Known hypersensitivity to calcium folinate, or to any of the excipients

Pernicious anaemia or other anaemias due to vitamin B12 deficiency.

Regarding the use of calcium folinate with methotrexate or 5-fluorouracil during pregnancy and lactation, see section 4.6, “Pregnancy and Lactation” and the summaries of product characteristics for methotrexate- and 5-fluorouracil- containing medicinal products.

4.4 Special warnings and precautions for use

Calcium folinate should only be given by intramuscular or intravenous injection and must not be administered intrathecally. When folinic acid has been administered intrathecally following intrathecal overdose of methotrexate, death has been reported.

General

Calcium folinate should be used with methotrexate or 5-fluorouracil under the direct supervision of a clinician experienced in the use of cancer chemotherapeutic agents.

Calcium folinate treatment may mask pernicious anaemia and other anaemias resulting from vitamin B12 deficiency.

Many cytotoxic medicinal products – direct or indirect DNA synthesis inhibitors – lead to macrocytosis (hydroxycarbamide, cytarabine, mercaptopurine, thioguanine). Such macrocytosis should not be treated with folinic acid.

In epileptic patients treated with phenobarbital, phenytoine, primidone, and succinimides there is a risk to increase the frequency of seizures due to a decrease of plasma concentrations of anti-epileptic drugs. Clinical monitoring, possibly monitoring of the plasma concentrations and, if necessary, dose adaptation of the anti-epileptic drug during calcium folinate administration and after discontinuation is recommended (see also section 4.5 Interactions).

The use of diluting infusion fluids containing sodium should be borne in mind when treating patients requiring a restricted sodium intake.

Calcium  folinate/5-fluorouracil:

Calcium folinate may enhance the toxicity risk of 5-fluorouracil, particularly in elderly or debilitated patients. The most common manifestations are leucopenia, mucositis, stomatitis and/or diarrhoea which may be dose limiting. When calcium folinate and 5-fluorouracil are used in combination, the 5-fluorouracil dosage has to be reduced more in cases of toxicity than when 5-fluorouracil is used alone.

Combined 5-fluorouracil/cal­cium folinate treatment should neither be initiated nor maintained in patients with symptoms of gastrointestinal toxicity, regardless of the severity, until all of these symptoms have completely disappeared.

Because diarrhoea may be a sign of gastrointestinal toxicity, patients presenting with diarrhoea must be carefully monitored until the symptoms have disappeared completely, since a rapid clinical deterioration leading to death can occur. If diarrhoea and/or stomatitis occur, it is advisable to reduce the dose of 5-FU until symptoms have fully disappeared. Especially the elderly and patients with a low physical performance due to their illness are prone to these toxicities. Therefore, particular care should be taken when treating these patients.

In elderly patients and patients who have undergone preliminary radiotherapy, it is recommended to begin with a reduced dosage of 5-fluorouracil.

Calcium folinate must not be mixed with 5-fluorouracil in the same IV injection or infusion.

Calcium levels should be monitored in patients receiving combined 5-fluorouracil/cal­cium folinate treatment and calcium supplementation should be provided if calcium levels are low.

Calcium  folinate/met­hotrexate:

For specific details on reduction of methotrexate toxicity refer to the SPC of methotrexate.

Calcium folinate has no effect on non-haematological toxicities of methotrexate such as the nephrotoxicity resulting from methotrexate and/or metabolite precipitation in the kidney. Patients who experience delayed early methotrexate elimination are likely to develop reversible renal failure and all toxicities associated with methotrexate (please refer to the SPC for methotrexate). The presence of pre-existing or methotrexate-induced renal insufficiency is potentially associated with delayed excretion of methotrexate and may increase the need for higher doses or more prolonged use of calcium folinate.

Excessive calcium folinate doses must be avoided since this might impair the antitumour activity of methotrexate, especially in CNS tumours where calcium folinate accumulates after repeated courses.

Resistance to methotrexate as a result of decreased membrane transport implies also resistance to folinic acid rescue as both medicinal products share the same transport system.

An accidental overdose with a folate antagonist, such as methotrexate, should be treated as a medical emergency. As the time interval between methotrexate administration and calcium folinate rescue increases, calcium folinate effectiveness in counteracting toxicity decreases.

4.5 Interaction with other medicinal products and other forms of interaction

When calcium folinate is given in conjunction with a folic acid antagonist (e.g. co-trimoxazole, pyrimethamine), the efficacy of the folic acid antagonist may either be reduced or completely neutralised.

Calcium folinate may diminish the effect of anti-epileptic substances: phenobarbital, primidone, phenytoine, and succinimides, and may increase the frequency of seizures (a decrease of plasma levels of enzymatic inductor anticonvulsant drugs may be observed because the hepatic metabolism is increased as folates are one of the cofactors) (see also sections 4.4 and 4.8).

Concomitant administration of calcium folinate with 5-fluorouracil has been shown to enhance the efficacy and toxicity of 5-fluorouracil (see sections 4.2, 4.4 and 4.8).

4.6 Fertility, pregnancy and lactation

Pregnancy

There are no adequate and well-controlled clinical studies conducted in pregnant or breast-feeding women. No formal animal reproductive toxicity studies with calcium folinate have been conducted. There are no indications that folic acid induces harmful effects if administered during pregnancy. During pregnancy, methotrexate should only be administered on strict indications, where the benefits of the drug to the mother should be weighted against possible hazards to the foetus. Should treatment with methotrexate or other folate antagonists take place despite pregnancy or lactation, there are no limitations as to the use of calcium folinate to diminish toxicity or counteract the effects.

5-fluorouracil use is generally contraindicated during pregnancy and contraindicated during breast-feeding; this applies also to the combined use of calcium folinate with 5-fluorouracil.

Please refer also to the summaries of product characteristics for methotrexate-, other folate antagonists and 5-fluorouracil- containing medicinal products.

Lactation

It is not known whether calcium folinate is excreted into human breast milk. Calcium folinate can be used during breast feeding when considered necessary according to the therapeutic indications.

4.7 Effects on ability to drive and use machines

There is no evidence that calcium folinate has an effect on the ability to drive or use machines.

4.8 Undesirable effects

Both therapeutic indications:

Very rare (<1/10,000): allergic reactions, including anaphylactoid / anaphylactic reactions, and urticaria

Rare (>1/10,000 to <1/1,000): insomnia, agitation and depression after high doses

Rare (>1/10,000 to <1/1,000): increase in the frequency of attacks in epileptics (see

also section 4.5 Interactions).

Rare (>1/10,000 to <1/1,000): gastrointestinal disorders after high doses.

Uncommon (>1/1,000 to <1/100): fever has been observed after administration of calcium folinate as solution for injection.

Combination therapy with 5-fluorouracil only:

Generally, the safety profile depends on the applied regimen of 5-fluorouracil due to enhancement of the 5-fluorouracil induced toxicities:

Not known (cannot be estimated from the available data): Hyperammonaemia

Very common (>1/10): bone marrow failure, including fatal cases

Very common (>1/10): Mucositis, including stomatitis and chelitis. Fatalities have occurred as a result of mucositis.

Common (>1/100 to <1/10): Palmar-Plantar Erythrodysaesthesia

Monthly regimen:

Gastrointestinal disorders

Very common (>1/10): vomiting and nausea

No enhancement of other 5-fluorouracil induced toxicities (e.g. neurotoxicity).

Weekly regimen:

Gastrointestinal disorders

Very common (>1/10): diarrhoea with higher grades of toxicity, and dehydration, resulting in hospital admission for treatment and even death.

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.

4.9 Overdose

There have been no reported sequelae in patients who have received significantly more calcium folinate than the recommended dosage. However, excessive amounts of calcium folinate may nullify the chemotherapeutic effect of folic acid antagonists.

Should overdosage of the combination of 5-fluorouracil and calcium folinate occur, the overdosage instructions for 5-fluorouracil should be followed.

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Detoxifying agents for antineoplastic treatment; ATC code: V03AF03

Calcium folinate is the calcium salt of 5-formyl tetrahydrofolic acid. It is an active metabolite of folinic acid and an essential coenzyme for nucleic acid synthesis in cytotoxic therapy.

Calcium folinate is frequently used to diminish the toxicity and counteract the action of folate antagonists, such as methotrexate. Calcium folinate and folate antagonists share the same membrane transport carrier and compete for transport into cells, stimulating folate antagonist efflux. It also protects cells from the effects of folate antagonist by repletion of the reduce folate pool.

Calcium folinate serves as a pre-reduced source of H4 folate; it can therefore bypass folate antagonist blockage and provide a source for the various coenzyme forms of folic acid.

Calcium folinate is also frequently used in the biochemical modulation of fluoropyridine (5-FU) to enhance its cytotoxic activity. 5-FU inhibits thymidylate synthase (TS), a key enzyme involved in pyrimidine biosynthesis, and calcium folinate enhances TS inhibition by increasing the intracellular folate pool, thus stabilising the 5FU-TS complex and increasing activity.

Finally intravenous calcium folinate can be administered for the prevention and treatment of folate deficiency when it cannot be prevented or corrected by the administration of folic acid by the oral route. This may be the case during total parenteral nutrition and severe malabsorption disorders. It is also indicated for the treatment of megaloblastic anaemia due to folic acid deficiency, when oral administration is not feasible.

5.2 Pharmacokinetic properties

Absorption

Following intramuscular administration of the aqueous solution, systemic availability is comparable to an intravenous administration. However, lower peak serum levels (Cmax) are achieved.

Metabolism

Calcium folinate is a racemate where the L-form (L-5-formyl-tetrahydrofolate, L-5-formyl-THF), is the active enantiomer.

The major metabolic product of folinic acid is 5-methyl-tetrahydrofolic acid (5-methyl-THF) which is predominantly produced in the liver and intestinal mucosa.

Distribution

The distribution volume of folinic acid is not known.

Peak serum levels of the parent substance (D/L-5-formyl-tetrahydrofolic acid, folinic acid) are reached 10 minutes after i.v. administration.

AUC for L-5-formyl-THF and 5-methyl-THF were 28.4±3.5 mg.min/l and 129±112 mg.min/l after a dose of 25 mg. The inactive D-isomer is present in higher concentration than L-5-formyl-tetrahydrofolate.

Elimination

The elimination half-life is 32 – 35 minutes for the active L-form and 352 –485 minutes for the inactive D-form, respectively.

The total terminal half life of the active metabolites is about 6 hours (after intravenous and intramuscular administration).

Excretion

80–90% with the urine (5– and 10-formyl-tetrahydrofolates inactive metabolites), 5–8% with the faeces.

5.3 Preclinical safety data

There are no preclinical data considered relevant to clinical safety beyond data included in other sections of the SPC.

6.1

Sodium chloride

Sodium hydroxide (for pH-adjustment)

Water for injections

Nitrogen

6.2

All forms of mixed infusions should be avoided. Calcium folinate solution should not be mixed with any other drug, unless compatibility has been satisfactorily demonstrated.

In particular, calcium folinate solution should not be mixed in the same infusion as fluorouracil because a precipitate may form.

Incompatibilities have been reported between injectable forms of calcium folinate and injectable forms of droperidol, fluorouracil, foscarnet, methotrexate and sodium bicarbonate.

6.3 Shelf life

Unopened vials: 24 months

After first opening: For Single Dose Use Only. Discard any unused solution immediately after initial use.

After dilution:

When diluted according to directions with 0.9% Sodium Chloride Injection or 5% Glucose Injection, chemical and physical in-use stability has been demonstrated when protected from light.

Chemical and physical in-use stability of Calcium Folinate Solution for Injection after dilution to 1.5 mg/ml with either 0.9% Sodium Chloride Injection or 5% Glucose Injection was demonstrated for up to 96 hours, at both room temperature and 2–8° C, when protected from light.

Chemical and physical in-use stability of Calcium Folinate Solution for Injection after dilution to 0.2 mg/ml with 0.9% Sodium Chloride Injection was demonstrated for up to 24 hours at 2–8° C, when protected from light.

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, unless dilution has taken place in controlled and validated aseptic conditions.

6.4 Special precautions for storage

Store at 2° C – 8° C (in a refrigerator).

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

6.5 Nature and contents of container

Colourless, neutral, Ph Eur Type I glass vial, with bromobutyl rubber stopper and aluminium flip-off closure, containing 5 ml, 10 ml, 20 ml, 35 ml, 50 ml or 100 ml solution for injection/infusion.

Original pack containing 1 (5 / 10) vial(s) of 5 ml (each).

Original pack containing 1 (5 / 10) vial(s) of 10 ml (each).

Original pack containing 1 (5 / 10) vial(s) of 20 ml (each).

Original pack containing 1 (5 / 10) vial(s) of 35 ml (each).

Original pack containing 1 (5 / 10) vial(s) of 50 ml (each).

Original pack containing 1 (5 / 10) vial(s) of 100 ml (each).

Not all pack sizes may be marketed.

6.6 Special precautions for disposal

Calcium Folinate Solution for Injection or Infusion is intended only for single use. Discard any unused solution immediately after initial use and also if precipitation occurs following dilution.

Prior to administration, Calcium Folinate Injection should be visually inspected. The solution for injection or infusion should be a clear and yellowish solution. If cloudy in appearance or particles are observed, the solution should be discarded.

The administration of calcium folinate depends on the individual dosage regime.

For slow intravenous infusion, Calcium Folinate Injection may be diluted with 0.9% Sodium Chloride Injection to give a final concentration within the range of 1.5 mg/ml to 0.2 mg/ml folinic acid, and with 5% Glucose Injection to give a final concentration of 1.5 mg/ml. The infusion rate should not exceed 160 mg of calcium folinate per minute. (For further instructions please see also section 4.2.).

For in-use stability of the prepared infusion solutions, please see section 6.3.

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

hameln pharmaceuticals ltd Gloucester

United Kingdom