EPHEDRINE HYDROCHLORIDE INJECTION 3 MG PER ML - summary of medicine characteristics

Ephedrine Hydrochloride 3mg per ml Injection

2 QUALITATIVE AND QUANTITATIVE COMPOSITION

Ephedrine Hydrochloride 0.3% w/v

Each ml of Solution for Injection contains 3 mg ephedrine hydrochloride.

Each 10 ml pre-filled syringe contains 30 mg ephedrine hydrochloride.

Excipients with known effect

Each ml of Solution for Injection contains 2.36 mg equivalent to 0.102 mmol of sodium.

Each 10 ml pre-filled syringe contains 23.6 mg equivalent to 1.02 mmol of sodium.

For a full list of excipients, see section 6.1.

Clear, colourless solution for Injection

pH = 4.5 – 6.5

4.1 Therapeutic indications

Reversal of hypotension from spinal or epidural anaesthesia

4.2 Posology and method of administration

Posology

Adults and children over 12 years and Elderly

Slow intravenous injection of a solution containing ephedrine hydrochloride 3mg/ml, 3–6mg (maximum of 9mg) repeated every 3–4 minutes to a maximum of 30mg.

Paediatrics

Children under 12 years

Not recommended

Method of administration

Ephedrine must be used solely by or under the supervision of the anaesthetist as an injection via intravenous route.

For intravenous use.

4.3 Contraindications

Known sensitivity to Ephedrine Hydrochloride or to any of the excipients listed in section 6.1.

In combination with other indirect sympathomimetic agents such as phenylpropano­lamine, phenylephrine, pseudoephedrine and methylphenidate.

In combination with alpha sympathomimetic agents.

In combination with non-selective Monoamine Oxidase Inhibitors (MAOI) or within 14 days of their withdrawal.

4.4 Special warnings and precautions for use

Warnings

Ephedrine should be used with caution in patients who may be particularly susceptible to their effects, particularly those with hyperthyroidism. Great care is also needed in patients with cardiovascular disease such as ischaemic heart disease, arrhythmia or tachycardia, occlusive vascular disorders including arteriosclerosis, hypertension, or aneurysms. Angina pain may be precipitated in patients with angina pectoris.

Care is also required when Ephedrine is given to patients with diabetes mellitus, closed-angle glaucoma or prostatic hypertrophy.

Ephedrine should be avoided or used with caution in patients undergoing anaesthesia with cyclopropane, halothane, or other halogenated anaesthetics, as they may induce ventricular fibrillation. An increased risk of arrhythmias may also occur if Ephedrine is given to patients receiving cardiac glycosides, quinidine, or tricyclic antidepressants.

Ephedrine increases blood pressure and therefore special care is advisable in patients receiving antihypertensive therapy. Interactions of Ephedrine with alpha- and betablocking drugs may be complex. Propranolol and other beta-adrenoceptor blocking agents antagonise the effects of beta2 adrenoceptor stimulants (beta2 agonists) such as salbutamol.

Adverse metabolic effects of high doses of beta2 agonists may be exacerbated by concomitant administration of high doses of corticosteroids; patients should therefore be monitored carefully when the 2 forms of therapy are used together although this precaution is not so applicable to inhaled corticotherapy. Hypokalaemia associated with high doses of beta2 agonists may result in increased susceptibility to digitalis-induced cardiac arrhythmias. Hypokalaemia may be enhanced by concomitant administration of aminophylline or other xanthines, corticosteroids, or by diuretic therapy.

Precautions for use

Ephedrine should be used with caution in patients with a history of cardiac disease.

Athletes should be informed that this preparation contains an active substance which might give a positive reaction in anti-doping tests.

Check that the solution is clear and contains no visible particles before infusion.

This medicinal product contains 23.6 mg of sodium per syringe: to be taken into consideration for patients on a controlled sodium diet.

4.5 Interaction with other medicinal products and other forms of interaction Contraindicated combinations:

Indirect sympathomimetic agents (phenylpropano­lamine, pseudoephedrine, phenylephrine, methylphenidate)

Risk of vasoconstriction and/or of acute episodes of hypertension.

Alpha sympathomimetics (oral and/or nasal route of administration)

Risk of vasoconstriction and/or episodes of hypertension.

Non-selective MAO inhibitors

Paroxysmal hypertension, hyperthermia possibly fatal.

Combinations not recommended:

Ergot alkaloids (dopaminergic action)

Risk of vasoconstriction and/or episodes of hypertension.

Ergot alkaloids (vasoconstrictors)

Risk of vasoconstriction and/or episodes of hypertension.

Selective MAO-A inhibitors (administered concomitantly or within the last 2 weeks)

Risk of vasoconstriction and/or episodes of hypertension.

Linezolid

Risk of vasoconstriction and/or episodes of hypertension

Tricyclic antidepressants (e.g. imipramine)

Paroxysmal hypertension with possibility of arrhythmias (inhibition of adrenaline or noradrenaline entry in sympathetic fibres).

Noradrenergic-serotoninergic antidepressants (minalcipran, venlafaxine)

Paroxysmal hypertension with possibility of arrhythmias (inhibition of adrenaline or noradrenaline entry in sympathetic fibres).

Guanethidine and related products

Substantial increase in blood pressure (hyper reactivity linked to the reduction in sympathetic tone and/or to the inhibition of adrenaline or noradrenaline entry in sympathetic fibres).

If the combination cannot be avoided, use with caution lower doses of sympathomimetic agents.

Sibutramine

Paroxysmal hypertension with possibility of arrhythmia (inhibition of adrenaline or noradrenaline entry in sympathetic fibres).

Halogenated volatile anaesthetics

Risk of peri-operative hypertensive crisis and serious ventricular arrhythmias.

Combinations requiring precautions for use:

Theophylline

Concomitant administration of ephedrine and theophylline may result in insomnia, nervousness and gastrointestinal complaints.

Corticosteroids

Ephedrine has been shown to increase the clearance of dexamethasone.

Antiepileptics: increased plasma concentration of phenytoin and possibly of phenobarbitone and primidone.

Doxapram: risk of hypertension

Oxytocin: hypertension with vasoconstrictor sympathomimetics

Hypotensive agents: reserpine and methyldopa may reduce the vasopressor action of ephedrine.

4.6 Fertility, pregnancy and lactation

Pregnancy

Studies in animals have shown a teratogenic effect.

Clinical data from epidemiological studies on a limited number of women appear to indicate no particular effects of ephedrine with respect to malformation.

Isolated cases of maternal hypertension have been described after abuse or prolonged use of vasoconstrictor amines.

Ephedrine crosses the placenta and this has been associated with an increase in foetal heart rate and beat-to-beat variability.

Therefore, ephedrine should be avoided or used with caution, and only if necessary, during pregnancy.

Breast-feeding

Ephedrine is excreted in breast milk. Irritability and disturbed sleep patterns have been reported in breast-fed infants. There is evidence that ephedrine is eliminated within 21 to 42 hours after administration, therefore a decision needs to be made on whether to avoid ephedrine therapy or lactation should be suspended for 2 days following its administration taking into account the benefit of breastfeeding for the child and the benefit of therapy for the woman.

4.7 Effects on ability to drive and use machines

Not applicable.

4.8 Undesirable effects

Very common: >1/10; Common: >1/100, <1/10; Uncommon: >1/1,000, <1/100; Rare: >1/10,000, <1/1,000; Very rare: <1/10,000; Not known: cannot be estimated from the available data

Blood and lymphatic system disorders:

Not known: primary haemostasis modifications

Immune system disorders:

Not known: hypersensitivity

Psychiatric disorders:

Common: confusion, anxiety, depression

Not known: psychotic states, fear, giddiness,

Nervous system disorders:

Common: nervousness, irritability, restlessness, weakness, insomnia, headache, sweating

Not known: tremor, hypersalivation

Eye disorders:

Not known: episodes of angle-closure glaucoma

Cardiac disorders:

Common: palpitations, hypertension, tachycardia

Rare: cardiac arrhythmias

Not known: angina pain, reflex bradycardia, cardiac arrest, hypotension

Vascular disorders:

Not known: cerebral haemorrhage

Respiratory, thoracic and mediastinal disorders:

Common: dyspnoea

Not known: pulmonary oedema

Gastrointestinal disorders:

Common: nausea, vomiting

Not known: reduced appetite

Renal and urinary disorders:

Rare: acute urinary retention

Investigations:

Not known: hypokalaemia, changes in blood glucose levels

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: Website: www.mhra.gov.uk/yellowcard.

4.9 Overdose

Symptoms

In the event of overdose, the occurrence of nausea, vomiting, fever, paranoid psychosis, ventricular and supraventricular arrhythmias, hypertension, respiratory depression, convulsions and coma are observed.

The lethal dose in humans is approximately 2 g corresponding to blood concentrations of approximately 3.5 to 20 mg/l.

Treatment

The treatment of ephedrine overdose with this product may require intensive supportive treatment. Slow intravenous injection of labetalol 50–200mg may be given with electrocardiograph monitoring for the treatment of supraventricular tachycardia. Marked hypokalaemia (<2.8 mmol.l-1) due to compartmental shift of potassium predisposes to cardiac arrhythymias and may be corrected by infusing potassium chloride in addition to propranolol and correcting respiratory alkalosis, when present.

A benzodiazepine and/or a neuroleptic agent may be required to control CNS stimulant effects.

For severe hypertension, parenteral antihypertensive options include intravenous nitrates, calcium channel blockers, sodium nitroprusside, labetalol or phentolamine. The choice of antihypertensive drug is dependent on availability, concomitant conditions and the clinical status of the patient.

5 PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Adrenergic and Dopaminergic Agent.

ATC code: C01CA26

Ephedrine is a sympathomimetic amine acting directly on the alpha and beta receptors and indirectly by increasing the release of noradrenaline by the sympathetic nerve endings. As with any sympathomimetic agent, ephedrine stimulates the central nervous system, the cardiovascular system, the respiratory system, and the sphincters of the digestive and urinary systems. Ephedrine is also a monoamine oxidase (MAO) inhibitor.

5.2 Pharmacokinetic properties

After intravenous administration, ephedrine is completely biologically available.

Excretion depends on urine pH:

From 73 to 99% (mean: 88%) in acidic urine,

From 22 to 35% (mean: 27%) in alkaline urine.

After parenteral administration, 77% of ephedrine is excreted in unchanged form in the urine.

The half-life depends on urine pH. When the urine is acidified at pH = 5, the half-life is 3 hours; when the urine is rendered alkaline at pH = 6.3, the half-life is approximately 6 hours.

5.3 Preclinical safety data

There is no pre-clinical data of relevance to the prescriber which is additional to that already included in other sections of the SmPC.

6 PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Sodium Chloride

Hydrochloric Acid

Water for Injections

Nitrogen

6.2 Incompatibilities

In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.

6.3 Shelf life

2 years.

6.4 Special precautions for storage

Store below 25°C.

Protect from light

Keep out of the sight and reach of children.

6.5. Nature and Contents of Container

Sterile solution for injection presented in a Glass (Type 1) 10ml prefilled syringe.

6.6 Special precautions for disposal

Use once and discard any remaining solution.

Not for dilution.

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

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 12064/0043

9 DATE OF FIRST AUTHORISATION/RENEWAL OF THEAUTHORISATION

Date of first authorisation: 15th May 1998